Nokea
A client is receiving lithium carbonate 600 mg T.I.D. to treat bipolar disorder. Which of these indicate early signs of toxicity?
- A. Ataxia and coarse hand tremors
- B. Vomiting, diarrhea and lethargy
- C. Pruritus, rash and photosensitivity
- D. Electrolyte imbalance and cardiac arrhythmias
Correct Answer: B
Rationale: Vomiting, diarrhea, and lethargy are early signs of lithium toxicity.
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A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2 hour-old newborn, which clinical finding requires the nurse to intervene?
- A. Cyanosis of hands and feet
- B. Heart rate of 165/min while crying
- C. Jitteriness
- D. Respirations of 60/min
Correct Answer: C
Rationale: Jitteriness (C) in a newborn of a diabetic mother suggests hypoglycemia, a common complication due to maternal hyperglycemia causing fetal hyperinsulinism. Immediate intervention (e.g., glucose testing) is needed. Acrocyanosis (A) is normal, heart rate 165/min while crying (B) is within range, and respirations of 60/min (D) are normal for a newborn.
The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately?
- A. Asymmetrical chest expansion and decreased breath sounds on the left
- B. Blood pressure 100/65 mm Hg (mean arterial pressure 77 mm Hg)
- C. Client complains of 6/10 pain at the needle insertion site
- D. Respiratory rate 24/min, pulse oximetry 94% on oxygen 2 L/min
Correct Answer: A
Rationale: Asymmetrical chest expansion and decreased breath sounds (A) suggest pneumothorax, a serious post-thoracentesis complication. Hypotension (B), pain (C), and mild tachypnea (D) are less urgent or expected.
An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents’ primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home?
- A. Demonstrate the procedure using simple English phrases
- B. Give the parents written instructions with picture illustrations
- C. Tell the parents to have a friend or relative come in to translate
- D. Use an interpreter via the telephone interpretation service
Correct Answer: D
Rationale: A professional interpreter (D) ensures accurate communication, critical for colostomy care. Simple English (A) risks misunderstanding, pictures (B) are insufficient alone, and informal translators (C) may lack medical accuracy.
A 1-year-old boy is hospitalized for a fractured femur. There is a PRN order for pain medication. What is the best way to assess the child for pain?
- A. Ask the parent who is present if the child appears to be in pain.
- B. Observe the child's behavior carefully.
- C. Ask the child where it hurts and how badly it hurts.
- D. Have the child look at pictures of faces and select the one that best describes how he feels right now.
Correct Answer: B
Rationale: A 1-year-old cannot verbalize pain; observing behavior (e.g., crying, guarding) is the most reliable pain assessment method.
The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply.
- A. Allow the client to refuse food if not feeling hungry
- B. Ask if the client is experiencing any pain or nausea
- C. Involve the client in meal planning and food selection
- D. Plan for loved ones to share mealtimes with the client
- E. Provide oral care before and after meals to alleviate dry mouth
Correct Answer: A,B,D,E
Rationale: Allowing food refusal (A) respects autonomy, assessing pain/nausea (B) addresses barriers to eating, shared mealtimes (D) provide comfort, and oral care (E) improves appetite. Meal planning (C) may overwhelm a cachectic client.