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A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which finding should the nurse report to the healthcare provider immediately?
- A. Weight gain.
- B. Dry mouth.
- C. Muscle rigidity.
- D. Drowsiness.
Correct Answer: C
Rationale: The correct answer is C: Muscle rigidity. This finding could be indicative of Neuroleptic Malignant Syndrome (NMS), a rare but serious side effect of antipsychotic medications like risperidone. NMS is characterized by severe muscle rigidity, fever, altered mental status, and autonomic dysfunction. Prompt medical intervention is crucial to prevent complications.
A: Weight gain is a common side effect of risperidone and is typically not considered an urgent issue.
B: Dry mouth is a common side effect of risperidone and can be managed with oral hygiene measures.
D: Drowsiness is a common side effect of risperidone and may improve over time or with dosage adjustments. It is not typically an immediate concern unless severe or accompanied by other worrisome symptoms.
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What assessments should the nurse prioritize for a client with portal hypertension admitted to the medical floor?
- A. Assessment of blood pressure and evaluation for headaches and visual changes
- B. Assessment for signs and symptoms of venous thromboembolism
- C. Daily weights and measurement of abdominal girth
- D. Monitoring blood glucose every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Daily weights and measurement of abdominal girth. Portal hypertension can lead to fluid retention and ascites, causing weight gain and abdominal distension. Monitoring these parameters helps assess fluid status and effectiveness of treatment.
A: Assessment of blood pressure and evaluation for headaches and visual changes is not a priority as they are not directly related to portal hypertension.
B: Assessment for signs and symptoms of venous thromboembolism is not a priority in this case unless there are specific risk factors present.
D: Monitoring blood glucose every 4 hours is not directly related to portal hypertension and is not a priority in this scenario.
A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?
- A. A pattern of distinct exacerbations and remissions
- B. Severe diarrhea
- C. An absence of blood in stool
- D. Involvement of the rectal mucosa
Correct Answer: C
Rationale: The correct answer is C: An absence of blood in stool. This suggests Crohn's disease over ulcerative colitis because Crohn's can involve any part of the GI tract and may not always present with blood in stool, in contrast to ulcerative colitis which typically involves the rectum and almost always presents with blood in stool due to continuous inflammation in the colon. Choices A, B, and D are more commonly associated with ulcerative colitis, which typically presents with a pattern of exacerbations and remissions, severe diarrhea, and rectal mucosal involvement.
A healthcare professional is preparing to administer digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablets. How many tablets should the healthcare professional administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: The correct answer is B: 2 tablets. To administer 0.25 mg of digoxin daily using 0.125 mg tablets, the healthcare professional should give 2 tablets. Each tablet is 0.125 mg, so 2 tablets will equal 0.25 mg, which is the required dose. The other choices are incorrect because administering 1 tablet would only provide 0.125 mg (half the required dose), administering 3 tablets would provide 0.375 mg (exceeding the required dose), and administering 4 tablets would provide 0.5 mg (double the required dose). Thus, the correct answer is to administer 2 tablets to achieve the prescribed 0.25 mg dose.
When creating a care plan for a 70-year-old obese client admitted to the postsurgical unit following a colon resection, the client's age and increased body mass index put them at increased risk for which complication in the postoperative period?
- A. Hyperglycemia
- B. Azotemia
- C. Falls
- D. Infection
Correct Answer: D
Rationale: The correct answer is D: Infection. Postoperative obese patients are at higher risk for surgical site infections due to impaired wound healing, decreased tissue oxygenation, and increased tissue pressure. Obesity also compromises the immune system, further increasing susceptibility to infections. Age is a risk factor for infection as well, as older adults may have weakened immune responses. Hyperglycemia (choice A) is a common issue in obese patients but not specifically related to postoperative complications. Azotemia (choice B) refers to elevated levels of nitrogen-containing compounds in the blood and is not directly related to obesity or age. Falls (choice C) are more related to mobility issues and environmental factors, not specifically to age and obesity in the postoperative period.
A client is being educated about type 2 diabetes. The educator can confirm that the client understands the primary treatment for type 2 diabetes when the client states what?
- A. I read that a pancreas transplant will provide a cure for my diabetes.
- B. I will take my oral antidiabetic agents when my morning blood sugar is high.
- C. I will make sure to follow the weight loss plan designed by the dietitian.
- D. I will make sure I call the diabetes educator when I have questions about my insulin.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Weight loss helps improve insulin sensitivity.
2. Managing weight is crucial for controlling blood sugar levels.
3. Dietitian-designed plans focus on balanced nutrition for diabetes management.
4. Weight loss can reduce the need for medication and improve overall health.
Summary of Incorrect Choices:
A: Pancreas transplant is not a primary treatment for type 2 diabetes.
B: Taking oral antidiabetic agents based on blood sugar levels is not ideal.
D: Contacting the diabetes educator for insulin questions is important but not primary treatment.