Nokea
A client undergoing 'cold-turkey' withdrawal from years of substance abuse is most at risk of serious life-threatening complications with which of the following substances?
- A. Heroin.
- B. Cocaine.
- C. Alcohol.
- D. Marijuana.
Correct Answer: C
Rationale: Alcohol withdrawal (C) can cause life-threatening complications like seizures and delirium tremens. Heroin (A), cocaine (B), and marijuana (D) withdrawal, while uncomfortable, are less likely to be fatal.
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The body part that would most likely display jaundice in the dark-skinned individual is the:
- A. Conjunctiva of the eye
- B. Soles of the feet
- C. Roof of the mouth
- D. Shins
Correct Answer: A
Rationale: The conjunctiva of the eye is the most reliable site to assess jaundice in dark-skinned individuals, as it is less affected by skin pigmentation.
A client scheduled for a cardiac catheterization tells the nurse, 'My mother died during this same procedure 10 years ago. I'm afraid the same thing will happen to me.' Which of the following responses by the nurse is the most appropriate?
- A. It's normal to be scared. You are safe here. Let's discuss the procedure.
- B. I'll ask the cardiologist to come and speak with you about your concerns.
- C. We have the best outcomes of any facility in the area for this procedure.
- D. Don't worry. The procedure has improved a lot in the last 10 years.
Correct Answer: A
Rationale: Acknowledging the client’s fear and discussing the procedure provides reassurance and addresses concerns therapeutically.
The nurse is assisting a client with diverticulitis to select appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peach
- C. Tomato and cucumber salad
- D. Dinner roll
Correct Answer: C
Rationale: Clients with diverticulitis should avoid foods with seeds, such as tomatoes and cucumbers, as they can irritate diverticula. Bran, peaches, and dinner rolls are generally safe.
A.ls with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
- A. Treat iron-deficiency anemia caused by chemotherapeutic agents
- B. Create a synergistic effect that shortens treatment time
- C. Increase the number of circulating neutrophils
- D. Reverse drug toxicity and prevent tissue damage
Correct Answer: D
Rationale: Leucovorin calcium is given as a rescue therapy to reverse the toxic effects of trimetrexate, protecting healthy cells from damage.
The nurse is assessing a client with a closed reduction of a fractured femur. Which finding should the nurse report to the physician?
- A. Chest pain and shortness of breath.
- B. Ecchymosis on the side of the injured leg.
- C. Oral temperature of 99.2°F.
- D. Complaints of level two pain on a scale of five.
Correct Answer: A
Rationale: Chest pain and shortness of breath may indicate a pulmonary embolism, a serious complication requiring immediate reporting.