Nokea
A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?
- A. Somnambulism
- B. Dry mouth
- C. Vivid dreams
- D. Daytime sleepiness
Correct Answer: A
Rationale: The correct answer is A, 'Somnambulism' (sleepwalking). Somnambulism is a potentially dangerous side effect that should be reported to the healthcare provider immediately. Sleepwalking can pose risks to the individual's safety and may indicate a serious adverse reaction to the medication. Dry mouth (choice B), vivid dreams (choice C), and daytime sleepiness (choice D) are common side effects of ramelteon and are generally not considered as urgent or serious as somnambulism. While these side effects can impact the client's quality of life, they are not typically associated with immediate safety concerns.
You may also like to solve these questions
A client receiving chemotherapy reports severe nausea. What should the nurse implement first?
- A. Administer an antiemetic as prescribed.
- B. Offer the client small, frequent meals.
- C. Provide the client with crackers and water.
- D. Encourage the client to eat a bland diet.
Correct Answer: A
Rationale: The correct answer is A: Administer an antiemetic as prescribed. When a client receiving chemotherapy reports severe nausea, the priority action is to administer an antiemetic medication as prescribed. Antiemetics help alleviate nausea and prevent complications associated with chemotherapy, such as dehydration and malnutrition. Options B, C, and D focus on dietary interventions which can be helpful but addressing the severe nausea with antiemetic medication takes precedence to provide immediate relief and ensure the client's comfort and well-being.
A client with a urinary tract infection (UTI) is prescribed antibiotics. What is the most important instruction for the nurse to give the client?
- A. Take the antibiotics with food
- B. Complete the full course of antibiotics
- C. Increase fluid intake to at least 2 liters per day
- D. Take over-the-counter pain relievers for discomfort
Correct Answer: B
Rationale: The most crucial instruction for the nurse to give a client with a UTI who is prescribed antibiotics is to complete the full course of antibiotics. Completing the full course of antibiotics is essential to ensure that the infection is fully treated and to prevent the development of antibiotic resistance. While taking antibiotics with food, increasing fluid intake, and managing discomfort with pain relievers are important aspects of UTI management, completing the prescribed course of antibiotics is the top priority to achieve the best treatment outcomes and prevent recurrence of the infection.
A client is admitted with a large bowel obstruction. What finding should the nurse report immediately?
- A. Absence of bowel sounds in all four quadrants.
- B. Abdominal distention with a firm, rigid abdomen.
- C. Frequent, small, liquid stools.
- D. Nausea and vomiting that worsens after meals.
Correct Answer: B
Rationale: Abdominal distention with a firm, rigid abdomen is a concerning sign that may indicate perforation, which requires immediate intervention. The rigidity suggests a complication of the large bowel obstruction. Absence of bowel sounds in all four quadrants, option A, is a common finding in a bowel obstruction but not as alarming as a rigid abdomen. Frequent, small, liquid stools, option C, are not typical findings in a large bowel obstruction; instead, constipation is more common. Nausea and vomiting that worsens after meals, option D, are also common symptoms of a bowel obstruction but do not indicate an immediate life-threatening complication like a perforation.
A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
- A. Inform the healthcare provider
- B. Determine the client's need for pain medication
- C. Begin comfort measures
- D. Ensure all life-saving equipment is removed
Correct Answer: B
Rationale: The correct priority action for the nurse to implement in this scenario is to determine the client's need for pain medication. Ensuring that the client is comfortable and free from pain is crucial in end-of-life care, especially for a client with a Do Not Resuscitate (DNR) order. This action prioritizes the client's comfort and dignity in their final moments. While informing the healthcare provider and beginning comfort measures are important aspects of care, pain management takes precedence as the immediate priority. Removing life-saving equipment is not appropriate at this stage as it goes against the client's wishes stated in the DNR order.
A male client with heart failure becomes short of breath, anxious, and has pink frothy sputum. What is the first action the nurse should take?
- A. Consult the charge nurse about administering morphine.
- B. Administer the morphine sulfate as prescribed.
- C. Withhold the morphine until the dyspnea resolves.
- D. Review the need for the morphine prescription with the provider.
Correct Answer: B
Rationale: The correct answer is B: Administer the morphine sulfate as prescribed. In this situation, the client is experiencing symptoms of acute pulmonary edema, a complication of heart failure. Morphine is indicated as it helps reduce anxiety and respiratory distress by decreasing preload and afterload. It dilates blood vessels, reducing the workload of the heart and improving oxygenation. The priority is to administer the morphine promptly to alleviate the client's distress and improve oxygenation. Consulting the charge nurse (A) or reviewing the need for the morphine prescription with the provider (D) would cause a delay in providing essential treatment. Withholding the morphine (C) would not be appropriate as it is indicated for this condition.