Nokea
A client with a diagnosis of bipolar disorder is prescribed lithium. The nurse should monitor the client for which of the following early signs of toxicity?
- A. Tremors.
- B. Weight loss.
- C. Increased appetite.
- D. Dry skin.
Correct Answer: A
Rationale: Tremors are an early sign of lithium toxicity, requiring prompt monitoring and potential dose adjustment.
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The nurse is assessing a client with a suspected appendicitis. Which of the following findings is most indicative of this condition?
- A. Right lower quadrant pain.
- B. Left upper quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Right lower quadrant pain is a hallmark sign of appendicitis due to localized peritoneal irritation.
You have loosely applied a bed sheet around your client's waist to prevent a fall from the chair. What have you done?
- A. Ensured the client's safety which is a high patient care priority
- B. Violated Respondeat Superior
- C. Violated the client's right to dignity
- D. Committed a crime
Correct Answer: D
Rationale: Applying a bed sheet around the client's waist without a proper restraint order constitutes an illegal restraint, which is a crime , as it restricts freedom without proper authorization or consent.
The clinic nurse is reviewing the laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following laboratory findings indicates that the allopurinol is having the desired effect?
- A. Decreased serum uric acid level.
- B. Decreased serum potassium level.
- C. Increased serum calcium level.
- D. Increased hemoglobin level.
Correct Answer: A
Rationale: Allopurinol reduces serum uric acid levels by inhibiting xanthine oxidase, which is its therapeutic effect in treating gout.
On the first postpartum day, the nurse is caring for a primiparous client who has recently emigrated from Japan to the United States and speaks only a little English. The nurse observes that the client has been bottle-feeding her neonate on occasion, but most of the neonatal care is being performed by the client's mother-in-law. Which of the following actions would be most appropriate?
- A. Notify the social worker because bonding may be affected.
- B. Document the unusual maternal behavior in the client's chart.
- C. Determine whether this is a cultural practice for the client and her family.
- D. Obtain an order to make a home visit after the client's discharge.
Correct Answer: C
Rationale: Assessing whether the mother-in-law's involvement is a cultural practice respects the client's background and avoids misjudging normal family dynamics.
A client has been diagnosed with atrial fibrillation. The physician ordered warfarin (Coumadin) to be taken on a daily basis. The nurse instructs the client to avoid using which of the following over-the-counter medications while taking warfarin?
- A. Aspirin
- B. Diphenhydramine (Benadryl)
- C. Digoxin (Lanoxin)
- D. Pseudoephedrine (Sudafed)
Correct Answer: A
Rationale: Aspirin increases bleeding risk when taken with warfarin, a blood thinner, and should be avoided. Other listed medications have less significant interactions with warfarin.