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A client tells the nurse that he is going to harm his brother-in-law, who called the police on him for threatening to hurt his ex-wife. The nurse should notify which of the following persons? Select all that apply.
- A. Agency administrators.
- B. Ex-wife.
- C. Police.
- D. Intended victim.
- E. Social service department.
Correct Answer: C,D
Rationale: The nurse has a duty to warn the intended victim (brother-in-law) and notify the police due to the credible threat of harm. Notifying administrators or social services may be secondary, and the ex-wife is not the current target.
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The nurse walks into the room of a client who has a 'do not resuscitate' order and finds the client without a pulse, respirations, or blood pressure. What is the most appropriate action?
- A. Stay in the room and notify the nursing team for assistance.
- B. Push the emergency alarm to call a code.
- C. Dial the hospital phone number for a code.
- D. Pull the curtain and leave the room.
Correct Answer: D
Rationale: For a DNR client, no resuscitation is performed. The nurse should respectfully leave the room after ensuring privacy, notifying the team as needed for post-mortem care.
How many mL of a liquid medication would you administer intramuscularly using the below information? Doctor's order: 10 mg of medication BID Medication label: 1 mL = 12 mg
- A. 0.8 mL
- B. 0.9 mL
- C. 0.75 mL
- D. 0.125 mL
Correct Answer: A
Rationale: To calculate: 10 mg ÷ 12 mg/mL = 0.833 mL, rounded to 0.8 mL for practical administration.
The nurse is delivering care to a client who is diagnosed with toxic shock syndrome (TSS). Which complication of this syndrome should the nurse monitor the client for?
- A. Pulmonary embolism
- B. Vitamin K deficiency
- C. Factor VIII deficiency
- D. Disseminated intravascular coagulopathy (DIC)
Correct Answer: D
Rationale: TSS is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this complication, and notifies the primary health care provider promptly if signs and symptoms are noted. The other options are not complications of TSS.
A client with a history of type 2 diabetes mellitus is prescribed metformin (Glucophage). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild nausea.
- B. Metallic taste.
- C. Lactic acidosis symptoms.
- D. Weight gain.
Correct Answer: C
Rationale: Lactic acidosis is a rare but serious side effect of metformin, requiring immediate reporting of symptoms like muscle pain or weakness.
A school-age child diagnosed with attention deficit hyperactivity disorder is prescribed methylphenidate (Ritalin). Which of the following should alert the school nurse to the possibility that the child is experiencing a common side effect of the drug?
- A. Loss of appetite
- B. Vomiting
- C. Photosensitivity
- D. Weight gain
Correct Answer: A
Rationale: Loss of appetite is a common side effect of methylphenidate, often leading to weight loss. Vomiting and photosensitivity are less common, and weight gain is not typical.