Nokea
A client with a history of bipolar disorder is receiving Lithium. The nurse should teach the client to:
- A. Avoid salty foods
- B. Increase fluid intake
- C. Take the medication with meals
- D. Monitor for weight loss
Correct Answer: B
Rationale: Lithium can cause dehydration and toxicity, so increasing fluid intake is essential. Salty foods are not contraindicated, meals are optional, and weight loss is not a primary concern.
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The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Hypothermia
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect. Hypothermia (B), nausea (C), and hyperactivity (D) are not associated with clopidogrel.
A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:
- A. Afterbirth pains
- B. Constipation
- C. Cystitis
- D. A hematoma of the vagina or vulva
Correct Answer: D
Rationale: Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. Constipation may cause rectal pressure but is not usually associated with 'severe pain.' Cystitis may cause pain, but the location is different. Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most likely to be observed?
- A. Fever
- B. Tachycardia
- C. Hypotension
- D. All of the above
Correct Answer: D
Rationale: Postpartum endometritis a uterine infection can cause fever (from infection) tachycardia (from systemic response) and hypotension (in severe cases). All vital sign changes may be observed.
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
- A. Airway obstruction
- B. Communication impairment
- C. Pain management
- D. Infection risk
Correct Answer: C
Rationale: Pain management is a priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy due to the surgical incision and tissue trauma, which can cause significant discomfort. Effective pain control is essential to promote recovery and patient comfort.
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. Immediate treatment of mild PIH includes the administration of a variety of medications
- B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
- C. Self-discipline is required to control caloric intake throughout the pregnancy
- D. The client may not recognize the early symptoms of PIH
Correct Answer: D
Rationale: Mild PIH is not treated with medications. Emotional stress is not the cause of blood pressure elevation in PIH. Excessive caloric intake is not the cause of weight gain in PIH. The client most frequently is not aware of the signs and symptoms in mild PIH.