Nokea
A client with a diagnosis of rheumatoid arthritis is prescribed adalimumab (Humira). 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: Adalimumab, a TNF inhibitor, increases the risk of infections due to immune suppression.
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Your client in crisis is detaching from self. Which psychological ego defense mechanism is this client most likely using?
- A. Displacement
- B. Sublimation
- C. Dissociation
- D. Reaction formation
Correct Answer: C
Rationale: Dissociation is the defense mechanism where a person detaches from their sense of self or reality to cope with overwhelming stress or trauma, which aligns with the client's behavior.
What is the primary goal of multidisciplinary case conferences?
- A. To fulfill the nurse's role in terms of collaboration
- B. To plan and provide for optimal client outcomes
- C. To solve complex multidisciplinary patient care problems
- D. To provide educational experiences for experienced nurses
Correct Answer: B
Rationale: The primary goal of multidisciplinary case conferences is to plan and provide for optimal client outcomes by bringing together various professionals to coordinate care and address the client's needs holistically.
A client with a history of heart failure is admitted with shortness of breath. The nurse should place the client in which of the following positions?
- A. Supine.
- B. Prone.
- C. Fowler's position.
- D. Trendelenburg position.
Correct Answer: C
Rationale: Fowler's position (semi-sitting) promotes lung expansion and reduces cardiac workload in heart failure clients with shortness of breath.
A client taking clozapine (Clozaril) states, 'I think I'm getting the flu. I have a fever and feel weak.' Which of the following should the nurse do next?
- A. Tell the client to wait another day to see if other symptoms of the flu appear.
- B. Advise the client to take over-the-counter medication for the flu.
- C. Discuss the importance of maintaining an adequate fluid intake.
- D. Report the client's symptoms to the physician after taking the client's temperature.
Correct Answer: D
Rationale: Fever and weakness in a client taking clozapine may indicate agranulocytosis, a serious side effect, requiring immediate physician notification after confirming the temperature.
A postoperative client is prescribed incentive spirometry. What is the primary purpose of this intervention?
- A. Prevent atelectasis.
- B. Reduce incisional pain.
- C. Improve circulation.
- D. Promote wound healing.
Correct Answer: A
Rationale: Incentive spirometry encourages deep breathing to expand alveoli, preventing atelectasis after surgery.