Nokea
A client is taking 600 mg of valproic acid (Depakene) twice daily. The nurse should assess the client for which of the following? Select all that apply.
- A. Tremors.
- B. Hair loss.
- C. Gastrointestinal upset.
- D. Anorexia.
- E. Weight gain.
Correct Answer: A,C,E
Rationale: Valproic acid commonly causes tremors, gastrointestinal upset (e.g., nausea), and weight gain. Hair loss and anorexia are less common side effects.
You may also like to solve these questions
The nurse is assigned to a client with jaundice and collects the following data: poor appetite, nausea, and two episodes of emesis in the past 2 hours. The nurse should make which of the following nursing diagnoses?
- A. Imbalanced nutrition: Less than body requirements.
- B. Acute pain related to abdominal muscle spasms.
- C. Adult failure to thrive.
- D. Ineffective health maintenance.
Correct Answer: A
Rationale: Poor appetite, nausea, and vomiting indicate inadequate nutritional intake, supporting the diagnosis of imbalanced nutrition.
The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following?
- A. I can lay my child flat and feed that way.'
- B. I'll raise my child's head up and leave the hips and legs on a pillow.'
- C. I can borrow a special feeding table to use.'
- D. It will take two of us, one to hold and one to feed.'
Correct Answer: B
Rationale: Raising the infant's head while keeping the hips and legs supported minimizes the risk of aspiration and accommodates the hip spica cast's restrictions. Laying flat increases aspiration risk, and the other options are impractical or unnecessary.
Which of the following actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.
- A. Have the client state his or her name.
- B. Check the name on the arm band with the name on the medication.
- C. Learn to recognize the client.
- D. Check the client's room number.
- E. Compare the date of birth on the client's chart to the date of birth on the client's armband.
Correct Answer: A,B,E
Rationale: Using two identifiers, such as the client's name, armband, and date of birth, ensures accurate medication administration. Room number and visual recognition are not reliable.
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when the nurse is
- A. I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: A
Rationale: Suspecting a bladder infection requires immediate medical evaluation, not just a visit to the obstetrician, as infections can trigger preterm labor. The other statements reflect correct understanding of preterm labor management.
The nurse is caring for a neonate with jaundice receiving phototherapy. Which action is most important?
- A. Cover the neonate's eyes.
- B. Apply lotion to the skin.
- C. Keep the neonate swaddled.
- D. Monitor urine output daily.
Correct Answer: A
Rationale: Covering the neonate's eyes protects them from retinal damage due to phototherapy light exposure.