Nokea
A client with a history of depression is prescribed paroxetine (Paxil). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Suicidal thoughts.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Suicidal thoughts are a serious side effect of paroxetine, requiring immediate reporting to ensure client safety.
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A client being treated for a comminuted fractured tibia asks the nurse to explain what a comminuted fracture means. The nurse should give which response?
- A. It means the fracture is incomplete.
- B. It means the bone is partially fractured.
- C. It means the bone fractured with splintering of the bone into fragments.
- D. It means the skin or mucous membrane was broken when the fracture occurred.
Correct Answer: C
Rationale: A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone. One side of the bone is fractured, and the other side is bent. A compound fracture, also called an open fracture, is one in which the skin or mucous membrane has been broken, and the wound extends to the depth of the fractured bone.
A nurse is teaching a client about crutch walking. Which of the following instructions should the nurse include?
- A. Bear weight on the axillae
- B. Keep elbows extended while walking
- C. Place crutches 6–10 inches to the side and front
- D. Step with the affected leg first
Correct Answer: C
Rationale: Crutches should be placed 6–10 inches to the side and front for stability. Weight is borne on hands, elbows are flexed, and the unaffected leg steps first.
A nurse is caring for a woman who delivered a term neonate at 6 a.m. At 4 p.m., the woman has a distended bladder and is reporting pain of 5 on a scale of 1 to 10. The nurse reviews the client's output record. What should the nurse do first?
- A. Apply a warm, moist towel over the bladder.
- B. Ask the woman to sit on the toilet while the nurse runs water from the faucet.
- C. Administer Tylenol with codeine.
- D. Use an in-and-out catheter to empty the bladder.
Correct Answer: D
Rationale: A distended bladder causing pain requires immediate relief via catheterization to prevent complications like urinary retention or bladder injury.
The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?
- A. Implementing relaxation exercises.
- B. Administering a sedative as needed.
- C. Administering prophylactic antacids or histamine-2 receptor antagonists.
- D. Monitoring the client's nutritional status closely.
Correct Answer: C
Rationale: Prophylactic antacids or H2 receptor antagonists reduce gastric acid, preventing stress ulcers in burn patients, who are at high risk due to stress response.
What type of immunity occurs when a person has an infectious, communicable disease like the measles?
- A. Adaptive immunity
- B. Passive natural immunity
- C. Active natural immunity
- D. Active artificial immunity
Correct Answer: C
Rationale: Active natural immunity occurs when a person develops immunity after exposure to an infectious disease like measles, producing antibodies through natural infection.