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A client with a history of Addison's disease is prescribed hydrocortisone. The nurse should instruct the client to report which of the following side effects immediately?
- A. Weight gain.
- B. Hypoglycemia.
- C. Mood changes.
- D. Muscle weakness.
Correct Answer: C
Rationale: Mood changes may indicate corticosteroid excess, requiring immediate reporting to adjust the hydrocortisone dose.
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Identify this cardiac rhythm strip. Fill in the blank. A. Third Degree Heart Block B. Second-Degree Atrioventricular Block, Type II C. Ventricular fibrillation D. Premature Atrial Contractions
- B. Third Degree Heart Block
- C. Second-Degree Atrioventricular Block, Type II
- D. Ventricular fibrillation
- E. Premature Atrial Contractions
Correct Answer: A
Rationale: Third Degree Heart Block shows complete dissociation between P waves and QRS complexes, assuming the strip matches this description.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart A. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart B. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate’s extremities.
Correct Answer: B
Rationale: The neonate’s Apgar score has been improving since birth. (The birth score is 6; the current score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is
needed since the color is improving, and stimulating the baby is not necessary as the he is now fl exing his extremities.
A client with a history of Parkinson's disease is prescribed levodopa/carbidopa (Sinemet). Which instruction should the nurse include?
- A. Take it with high-protein meals
- B. Avoid driving if drowsy
- C. Take it at bedtime only
- D. Crush the tablet for faster absorption
Correct Answer: B
Rationale: Levodopa/carbidopa can cause drowsiness, so clients should avoid driving if affected to ensure safety.
A client is scheduled for a colonoscopy. Which of the following instructions should the nurse include in the pre-procedure teaching?
- A. Avoid solid foods for 24 hours before the procedure.
- B. Take all regular medications the morning of the procedure.
- C. Expect to be sedated during the procedure.
- D. Plan to stay overnight in the hospital.
Correct Answer: A, C
Rationale: Clear liquid diet for 24 hours prevents residue, and sedation is common during colonoscopy. Regular medications may need adjustment, and overnight stays are not typical.
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.