Nokea
A client prescribed dextroamphetamine reports to the nurse difficulty falling asleep at night. The nurse instructs the client on how to minimize sleep disorders. Which statement by the client indicates that teaching has been effective?
- A. I'll take the medication with a bedtime snack.
- B. I'll take the medication upon awaking in the morning.
- C. I'll take the medication two hours before going to bed.
- D. I'll take the medication at least 6 hours before bedtime.
Correct Answer: D
Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from the nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep. Therefore, the remaining options are incorrect.
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An adult client seeks treatment in an ambulatory care clinic for reports of a left earache, nausea, and a full feeling in the left ear. The client has an elevated temperature. Which assessment question should the nurse ask first?
- A. Do you have a history of a recent brain abscess?
- B. Do you have a chronic hearing problem in the left ear?
- C. Do you successfully obtain pain relief with acetaminophen?
- D. Do you have a history of a recent upper respiratory infection (URI)?
Correct Answer: D
Rationale: Otitis media in the adult is typically one-sided and presents as an acute process with earache; nausea; and possible vomiting, fever, and fullness in the ear. The client may report diminished hearing in that ear during the acute process. The nurse takes a client history first, assessing whether the client has had a recent URI. It is unnecessary to question the client about a brain abscess. The nurse may ask the client if anything relieves the pain, but ear infection pain is usually not relieved until antibiotic therapy is initiated.
The nurse is performing a cardiovascular assessment on a client. Which item should the nurse assess to obtain the best information about the client's left-sided heart function?
- A. The status of breath sounds
- B. The presence of peripheral edema
- C. The presence of hepatojugular reflux
- D. The presence of jugular vein distention
Correct Answer: A
Rationale: The client with heart failure may present different symptoms depending on whether the right or the left side of the heart is failing. The assessment of breath sounds provides information about left-sided heart function. Peripheral edema, hepatojugular reflux, and jugular vein distention are all signs of right-sided heart function.
A client diagnosed with cirrhosis of the liver is receiving oral triamterene daily. Which sign/symptom would indicate to the nurse that the client is experiencing an adverse effect of the medication?
- A. Dry skin
- B. Excitability
- C. Constipation
- D. Hyperkalemia
Correct Answer: D
Rationale: Triamterene is a potassium-retaining diuretic. Adverse effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this is a potassium-retaining medication, which means that the concern with the administration of this medication is hyperkalemia. Other effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever.
A client at 35 weeks of gestation reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition should the nurse suspect?
- A. Miscarriage
- B. Preterm labor
- C. Intrauterine fetal demise
- D. Premature rupture of the membranes
Correct Answer: D
Rationale: Premature rupture of the membranes is usually manifested by a sudden discharge of fluid from the vagina before 37 weeks of gestation. Miscarriage is typically manifested by vaginal bleeding and abdominal pain. Preterm labor is typically manifested by uterine contractions, cramping, and pressure before 37 weeks of gestation. Intrauterine fetal demise is usually manifested by an absence of fetal movements and heartbeat.
The nurse reviews the record of a client who is receiving external radiation therapy and notes documentation of a skin finding as moist desquamation. Which finding on assessment of the client should the nurse expect to observe?
- A. A rash
- B. Dermatitis
- C. Reddened skin
- D. Weeping of the skin
Correct Answer: D
Rationale: Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. A rash, dermatitis, and reddened skin may occur with external radiation, but these conditions are not described as moist desquamation.