Nokea
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
- A. How long has the client been taking the medication?
- B. Assess the client's dietary habits.
- C. Check for signs of infection.
- D. Evaluate the client's sleep pattern.
Correct Answer: A
Rationale: The correct answer is A. When a client reports drowsiness while taking clonidine, the nurse should assess how long the client has been taking the medication. Drowsiness is a common side effect that can occur in the early weeks of treatment with clonidine. By understanding the duration of medication use, the nurse can determine if the drowsiness is a temporary effect that may decrease over time. Choices B, C, and D are incorrect because assessing the client's dietary habits, checking for signs of infection, or evaluating the client's sleep pattern would not directly address the drowsiness associated with clonidine use.
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When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take if a client is exhibiting an extrapyramidal reaction to psychotropic medications?
- A. Leave a detailed message about the client's condition.
- B. Tell the receptionist to have the healthcare provider return the phone call.
- C. Call another healthcare provider.
- D. Document the attempt to call the healthcare provider.
Correct Answer: B
Rationale: The best nursing action is to request a return call from the healthcare provider. When a client is experiencing an extrapyramidal reaction to psychotropic medications, it is crucial to prioritize the client's confidentiality and ensure the information is conveyed to the healthcare provider directly. Leaving a detailed message with a receptionist may compromise the confidentiality of the client's condition. Calling another healthcare provider may delay necessary intervention and continuity of care. Documenting the attempt to call is important for the nurse's records but does not address the immediate need to inform the healthcare provider about the client's condition.
During a home visit, the nurse observes that an elderly client has numerous bruises on her arms and appears fearful of her caregiver. What should the nurse do first?
- A. report the findings to adult protective services
- B. ask the client how she got the bruises
- C. document the observations in the client's medical record
- D. discuss the observations with the caregiver
Correct Answer: B
Rationale: The initial step for the nurse should be to ask the client how she got the bruises. This approach allows the nurse to directly assess the situation, gather information from the client, and potentially uncover signs of abuse. Reporting to adult protective services should come after obtaining more details from the client to ensure appropriate action. Documenting the observations is important but should follow gathering information from the client. Discussing the observations with the caregiver may not be appropriate as the caregiver could be the source of abuse, and involving them first may jeopardize the client's safety.
The nurse is documenting the medical history of a young adult who was recently diagnosed with type 1 diabetes mellitus. The client smokes 2 packs of cigarettes a day, and his father died of a heart attack at the age of 45. Which annual screening is most important for the nurse to include?
- A. peripheral neuropathy
- B. renal insufficiency
- C. retinopathy
- D. hyperlipidemia
Correct Answer: D
Rationale: The most important annual screening for the nurse to include is hyperlipidemia. Given the client's smoking history, family history of premature heart disease, and the increased risk of cardiovascular complications associated with diabetes, screening for hyperlipidemia is crucial. This screening is essential in assessing the client's risk of developing cardiovascular disease, which is a significant concern in this case. Peripheral neuropathy (choice A) is a common long-term complication of diabetes but may not be the most immediate concern in this scenario. Renal insufficiency (choice B) is also a complication of diabetes, but given the client's high cardiovascular risk, hyperlipidemia screening takes priority. Retinopathy (choice C) is an important complication of diabetes affecting the eyes, but in this case, focusing on cardiovascular risk assessment through hyperlipidemia screening is more critical.
The healthcare provider is caring for a client with hypokalemia. Which assessment finding requires immediate intervention?
- A. Muscle weakness.
- B. Irregular heart rate.
- C. Increased urinary output.
- D. Decreased deep tendon reflexes.
Correct Answer: D
Rationale: Decreased deep tendon reflexes are a critical finding in hypokalemia that indicates severe potassium deficiency affecting neuromuscular function. Immediate intervention is necessary to prevent life-threatening complications such as respiratory failure or cardiac arrhythmias. Muscle weakness, irregular heart rate, and increased urinary output are also associated with hypokalemia but do not pose the same level of urgency as decreased deep tendon reflexes.
On a day when the temperature is expected to drop below freezing during the night, the nurse is asked to determine which homeless adults are most in need of the limited spaces available in a shelter. It is most important for which person to be admitted at night?
- A. an adult who was hit by a car 3 weeks ago
- B. a young person with diabetes mellitus
- C. a middle-aged person who has hypertension
- D. an older person who is malnourished
Correct Answer: D
Rationale: Malnourished individuals are at higher risk of severe complications from cold exposure due to their weakened immune system and decreased ability to regulate body temperature. This places them at a greater risk of hypothermia and other cold-related conditions, making them the most vulnerable group in need of shelter. Choice A is not the most critical as the injury is from 3 weeks ago and should have received appropriate medical care by now. Choice B, a young person with diabetes mellitus, while vulnerable, can manage their condition with proper medication and care. Choice C, a middle-aged person with hypertension, may need monitoring but is less susceptible to immediate harm from cold exposure compared to a malnourished individual.