Nokea
A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?
- A. Call a chaplain
- B. Deny the feelings
- C. Cite recovery statistics
- D. Listen to the client
Correct Answer: D
Rationale: Listen to the client. Therapeutic communications are based on attentive listening to expressed feelings, followed by questions about cultural beliefs if needed.
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The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel is an antiplatelet medication that can increase the risk of bleeding, such as epistaxis (nosebleeds). Abdominal distention, nausea, and hyperactivity are not typical adverse effects of clopidogrel, so answers B, C, and D are incorrect.
A client who has a panic disorder is receiving paroxetine HCl (Paxil). The client has been taking the drug for one week and is still having severe panic attacks. The client tells the nurse that she thinks the drug is not working. What is the best response for the nurse to make?
- A. You should ask your physician for a different drug.
- B. The physician will probably add another drug to your regimen.
- C. You should stop taking the medication if it is not effective.
- D. It takes two to four weeks for Paxil to be effective.
Correct Answer: D
Rationale: Paroxetine, an SSRI, requires 2-4 weeks to reach therapeutic effect for panic disorder, explaining the continued symptoms.
The nurse is administering terbutaline (Brethine) to a client in labor.
- A. What is the priority action for the nurse if the client’s pulse is 144 before administering terbutaline?
- B. Withhold the medication.
- C. Decrease the dose by half.
- D. Administer the medication.
- E. Wait 15 minutes, then recheck the rate.
Correct Answer: A
Rationale: Terbutaline causes maternal tachycardia, and a pulse of 144 indicates a significant side effect. Withholding the medication is the priority to prevent further complications like pulmonary edema. Reducing the dose, administering, or delaying without action is unsafe.
The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment findings would suggest the complication of autonomic dysreflexia?
- A. Urinary bladder spasm pain.
- B. Severe pounding headache.
- C. Tachycardia.
- D. Severe hypotension.
Correct Answer: B
Rationale: severe headache results from rapid onset of hypertension
The nurse is teaching a client with a new diagnosis of chronic obstructive pulmonary disease (COPD) about tiotropium (Spiriva). Which of the following statements by the client indicates a need for further teaching?
- A. I should rinse my mouth after using this inhaler.
- B. I should use this inhaler once a day.
- C. I should report eye pain to my doctor.
- D. I should use this inhaler when I have trouble breathing.
Correct Answer: D
Rationale: Using tiotropium as a rescue inhaler is incorrect, as it is a long-acting maintenance medication for COPD, not for acute symptoms. Options A, B, and C are correct: rinsing prevents oral thrush, daily use is standard, and eye pain may indicate glaucoma.