Nokea
A client who has been taking diazepam (Valium) for 3 months for skeletal muscle spasms and the patient was a secret agent to the medication and the medication days ago because it was no longer helping him, but now he feels terrible. The nurse should assess the client for which of the following? Select all that apply.
- A. Insomnia.
- B. Euphoria.
- C. Bradycardia.
- D. Diaphoresis.
- E. Tremor.
- F. Vomiting.
Correct Answer: A, D, E, F
Rationale: Abrupt cessation of diazepam can cause withdrawal symptoms like insomnia, diaphoresis, tremor, and vomiting.
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A client with a history of type 2 diabetes mellitus is prescribed sitagliptin (Januvia). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Pancreatitis.
- C. Hypertension.
- D. Weight gain.
Correct Answer: B
Rationale: Sitagliptin can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.
The nurse is assessing a client with a suspected diverticulitis. Which of the following findings is most indicative of this condition?
- A. Left lower quadrant pain.
- B. Right upper quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Left lower quadrant pain is a hallmark sign of diverticulitis due to inflammation of diverticula in the sigmoid colon.
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown below. The nurse identifies that this rhythm is:
- A. Atrial fi brillation
- B. Ventricular tachycardia
- C. Premature ventricular contractions.
- D. Third-degree heart block.
Correct Answer: D
Rationale: Third-degree heart block occurs when atrial stimuli are blocked at the atrioventricular junction. Impulses from the atria and ventricles are conducted independently of each other. The atrial rate is 60 to 100 bpm; the ventricular rate is usually 10 to 60 bpm.
A client with pancreatitis is admitted with severe abdominal pain. Which position should the nurse encourage to reduce discomfort?
- A. Supine with legs elevated
- B. Side-lying with knees flexed
- C. Prone with a pillow under the abdomen
- D. Sitting upright
Correct Answer: B
Rationale: Side-lying with knees flexed reduces tension on the abdominal muscles and pancreas, helping to alleviate pain in pancreatitis.
An adolescent is being prepared for an emergency appendectomy. The nurse should tell the client? Select all that apply.
- A. Friends can visit whenever they want.
- B. The scar will be small.
- C. The teen will be back in school in 1 week.
- D. Antibiotics will be given to prevent an infection.
- E. A dressing will stay in place for 1 week.
Correct Answer: B,C,D
Rationale: A small scar, school return in about a week, and prophylactic antibiotics are accurate expectations for appendectomy recovery. Unrestricted visits and prolonged dressing use are incorrect.