Nokea
A client with a chronic mental illness who does not always take her medications is separated from her husband and receives Supplemental Security Income. She lives with her mother and older sister and manages her own medication. The client's mother is in poor health and receives Social Security benefits. The client's sister works outside the home, and the client's father is dead. Which of the following issues should the nurse need to address first?
- A. Family
- B. Marital
- C. Financial
- D. Medication
Correct Answer: D
Rationale: Medication non-adherence in a client with chronic mental illness is the priority issue, as it directly impacts mental stability and safety. Family, marital, and financial issues are secondary.
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A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, 'My boyfriend has been beating me up once in a while since I became pregnant'”but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children.' Which of the following actions should be the priority by the nurse at this time?
- A. Contact a social worker for assistance and family counseling.
- B. Help the client make concrete plans for the safety of herself and her children.
- C. Tell the client and how anyone to hit her or her children.
- D. Provide the client with brochures on the statistics about violence against women.
Correct Answer: B
Rationale: Prioritizing safety planning protects the client and her children from further abuse.
Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection?
- A. Close the day care center for 1 week to control the outbreak.
- B. Restrict the infected children from returning for 48 hours after treatment.
- C. Perform thorough hand washing before and after touching any child in the day care center.
- D. Set up a conference with the parents of each child to explain the situation carefully.
Correct Answer: C
Rationale: Thorough hand washing is the most effective measure to prevent the spread of bacterial conjunctivitis.
A client with a diagnosis of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following side effects?
- A. Infection.
- B. Hypotension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Etanercept, a TNF inhibitor, increases the risk of infections due to immune suppression.
Methylergonovine maleate is prescribed for a woman who has just delivered a healthy newborn. Which is the priority assessment to complete before administering the medication?
- A. Lochia
- B. Uterine tone
- C. Blood pressure
- D. Deep tendon reflexes
Correct Answer: C
Rationale: Methylergonovine maleate, an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose is administered intramuscularly, and then, if still needed, it is administered orally. It causes uterine contractions and may elevate the blood pressure. A priority assessment before administration of methylergonovine maleate is blood pressure. Methylergonovine maleate is to be administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension is present. Options 1 and 2 are general components of care in the postpartum period. Option 4 is most specifically related to the administration of magnesium sulfate.
A client with a history of chronic kidney disease is prescribed darbepoetin alfa (Aranesp). The nurse should monitor the client for which of the following side effects?
- A. Hypotension.
- B. Hypertension.
- C. Hypoglycemia.
- D. Weight loss.
Correct Answer: B
Rationale: Darbepoetin alfa can cause hypertension due to increased red blood cell production, requiring monitoring.