Nokea
A client with a history of bipolar disorder is prescribed lamotrigine (Lamictal). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Rash.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: A rash may indicate a serious hypersensitivity reaction to lamotrigine, such as Stevens-Johnson syndrome, requiring immediate reporting.
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A client with a history of depression is prescribed sertraline (Zoloft). The nurse should instruct the client to report which of the following side effects?
- A. Insomnia.
- B. Bradycardia.
- C. Hypotension.
- D. Weight loss.
Correct Answer: A
Rationale: Sertraline commonly causes insomnia, which should be reported to manage treatment.
The nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old. Where should the nurse administer the injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Gluteal muscle
- D. Subcutaneous tissue of the abdomen
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for intramuscular vaccines like MMR in toddlers due to adequate muscle mass and low risk of nerve damage.
During an appointment with the nurse, a client says, 'I need to find the good,' the nurse responds, 'Oh, don't feel that way. We're making progress in these sessions.' The nurse's statement demonstrates a failure to do which of the following?
- A. Look for meaning in what the client says.
- B. Explain to the client why he may think as he does.
- C. Add to the strength of the client's support system.
- D. Give the client credit for solving his own problems.
Correct Answer: A
Rationale: The nurse's response dismisses the client's statement, failing to explore its underlying meaning, which is essential for therapeutic communication.
A client's 12:00 noon blood glucose concentration was inaccurately documented as 310 instead of 130. This error was not noticed until 1:00 p.m. The nurse administered the sliding scale insulin for a blood glucose of 310 instead of 130. What should the nurse do first?
- A. Notify the physician.
- B. Assess for hypoglycemia.
- C. Consult with the clinical pharmacist.
- D. Call the charge nurse.
Correct Answer: B
Rationale: Administering insulin for a falsely high glucose level risks hypoglycemia, so assessing for symptoms (e.g., shakiness, sweating) is the priority.
Select the hazard of immobility that is accurately paired with an appropriate expected outcome of care that the nurse provides to prevent this complication.
- A. Bone demineralization: Turning and positioning every 2 hours
- B. Urinary stasis: The client will consume 1,000 mL of oral fluids per day
- C. Muscle atrophy: The client will perform range of motion exercises at least 3 times a day
- D. Hypercalcemia: Maintaining fluid intake of 1,000 mL per day
Correct Answer: C
Rationale: Range of motion exercises help prevent muscle atrophy by maintaining muscle strength and function in immobile clients.