Nokea
A client taking clozapine (Clozaril) states, 'I think I'm getting the flu. I have a fever and feel weak.' Which of the following should the nurse do next?
- A. Tell the client to wait another day to see if other symptoms of the flu appear.
- B. Advise the client to take over-the-counter medication for the flu.
- C. Discuss the importance of maintaining an adequate fluid intake.
- D. Report the client's symptoms to the physician after taking the client's temperature.
Correct Answer: D
Rationale: Fever and weakness in a client taking clozapine may indicate agranulocytosis, a serious side effect, requiring immediate physician notification after confirming the temperature.
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As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
- A. Place the client in a wheelchair to protect their safety in the clinic.
- B. Remove the cane from the client to protect their safety.
- C. Teach the client about the proper length of a cane.
- D. Have the client use a wheelchair rather than the cane.
Correct Answer: C
Rationale: Teaching the client about proper cane length (handle at wrist level when arm is relaxed) promotes safe and effective mobility.
Which nursing assessment findings indicate normal vital signs in a newborn infant?
- A. Pulse, 112; respiratory rate, 24
- B. Pulse, 124; respiratory rate, 28
- C. Pulse, 144; respiratory rate, 48
- D. Pulse, 164; respiratory rate, 55
Correct Answer: C
Rationale: The normal pulse rate for a newborn is 120 to 160. The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute. Therefore, the other options are incorrect.
Select all of the cranial nerves that are accurately paired with its distinguishing characteristics and description. Again, select all that apply.
- A. Olfactory Cranial Nerve: The sensory nerve that transmits the sense of smell to the olfactory foramina of the nose
- B. Optic Cranial Nerve: This sensory nerve transmits the sense of vision from the retina to the brain.
- C. Oculomotor Cranial Nerve: This motor and sensory nerve controls eye movements and visual acuity.
- D. Trochlear Cranial Nerve: This motor nerve innervates eye ball movement and the superior oblique muscle of the eyes.
- E. Abducens Cranial Nerve: This motor nerve innervates and controls the abduction of the eye using the lateral rectus muscle.
- F. Facial Cranial Nerve: This motor nerve controls facial movements, some salivary glands and gustatory sensations from the anterior part of the tongue.
- G. Glossopharyngeal Cranial Nerve: This sensory nerve This nerve gives us the sense of taste from the posterior tongue, and it also innervates the parotid glands
Correct Answer: A,B,D,E,F
Rationale: Options A, B, D, E, and F are correct. The olfactory nerve (I) is sensory for smell, the optic nerve (II) is sensory for vision, the trochlear nerve (IV) is motor for the superior oblique muscle, the abducens nerve (VI) is motor for the lateral rectus muscle, and the facial nerve (VII) is both motor and sensory, controlling facial movements and taste from the anterior tongue. Option C is incorrect because the oculomotor nerve (III) does not control visual acuity, and option G is incorrect because the glossopharyngeal nerve (IX) is both sensory and motor, not purely sensory.
Which sign/symptom indicates that a client being treated with haloperidol may be experiencing an adverse effect of this medication?
- A. Nausea
- B. Hypotension
- C. Blurred vision
- D. Excessive drooling
Correct Answer: D
Rationale: Adverse effects of antipsychotic medications such as haloperidol include marked drowsiness and lethargy; extrapyramidal symptoms, including parkinsonism effects (drooling); dystonias; akathisia; and tardive dyskinesia. The correct option is a parkinsonism effect of this medication, excessive drooling. Nausea, hypotension, and blurred vision are occasional side effects of the medication.
A client with a diagnosis of rheumatoid arthritis is prescribed methotrexate (Rheumatrex). The nurse should teach the client to avoid which of the following while taking this medication?
- A. Exposure to sunlight.
- B. Alcohol consumption.
- C. High-fiber foods.
- D. Regular exercise.
Correct Answer: B
Rationale: Alcohol consumption should be avoided with methotrexate due to the increased risk of hepatotoxicity.