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A client with a diagnosis of schizophrenia is prescribed olanzapine (Zyprexa). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Hypotension.
- C. Dry mouth.
- D. Tremors.
Correct Answer: A
Rationale: Olanzapine commonly causes weight gain, requiring monitoring in clients with schizophrenia.
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A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes?
- A. Allow the client to grieve for body image changes.
- B. Restrict foods that are high in potassium.
- C. Restrict fluid intake to 1,000 mL/day.
- D. Assess the client's mental status regularly.
Correct Answer: D
Rationale: Regularly assessing mental status monitors uremic encephalopathy progression, guiding timely interventions in chronic renal failure.
The registered nurse is observing a new nurse auscultate the breath sounds of a client. Which action by the new nurse should lead the registered nurse to determine that further teaching is needed?
- A. Uses the bell of the stethoscope
- B. Asks the client to sit straight up
- C. Places the stethoscope directly on the client's skin
- D. Encourages the client to breathe slowly and deeply through the mouth
Correct Answer: A
Rationale: The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should sit up and breathe slowly and deeply through the mouth. The diaphragm of the stethoscope, which is warmed before use, is placed directly on the client's skin, not over a gown or clothing.
Mebendazole (Vermox) is prescribed for an 8-year-old child with pinworms. The child has an 18-month-old brother and a 4-year-old sister. The nurse should be sure that the parents are also treating which of the following family members with this drug?
- A. Both of the child's siblings
- B. The child's parents and brother
- C. Everyone who lives in the household
- D. The parents and sister
Correct Answer: C
Rationale: Pinworms are highly contagious, so all household members should be treated with mebendazole to prevent reinfection, regardless of symptoms.
A client with a history of epilepsy is admitted with status epilepticus. The nurse should prioritize which of the following interventions?
- A. Administer lorazepam intravenously.
- B. Apply oxygen via nasal cannula.
- C. Insert a nasogastric tube.
- D. Position the client supine.
Correct Answer: A
Rationale: Lorazepam is the priority to stop seizures in status epilepticus.
The nurse is planning preoperative teaching with a client scheduled for a transurethral resection of the prostate (TURP). Which most frequent cause of postoperative pain should the nurse plan to include in the discussion?
- A. Bladder spasms
- B. Bleeding within the bladder
- C. Tension on the Foley catheter
- D. The lower abdominal incision
Correct Answer: A
Rationale: Bladder spasms can occur after this surgery because of postoperative bladder distention or irritation from the balloon on the indwelling urinary catheter. The nurse administers antispasmodic medications as prescribed to treat this type of pain. Options 2 and 3 are not frequent causes of pain. Some surgeons purposefully apply tension to the catheter for a few hours postoperatively to control bleeding. There is no incision with a TURP.