Nokea
A client with a history of depression is prescribed venlafaxine (Effexor). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Increased blood pressure.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Venlafaxine can cause increased blood pressure, requiring immediate reporting to prevent cardiovascular complications.
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A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When asking this client to complete a task, what techniques should the nurse use to communicate most effectively with him?
- A. Obtain eye contact before speaking, use simple language, and have him repeat what was said. Praise him if he completes the task.
- B. Fully explain to the client the actions required of him, offer verbal praise and a food reward for task completion.
- C. Explain to the client what he is to do, the consequences if he does not comply, and follow through with praise or consequences as appropriate.
- D. Demonstrate to the client what he is to do, have him imitate the nurse's actions, and give a food reward if he completes the task.
Correct Answer: A
Rationale: Clear, simple instructions with eye contact and repetition enhance communication for a child with ADHD, and praise reinforces positive behavior.
A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which of the following should the nurse include as the action of spermicides when teaching the client?
- A. Destruction of spermatozoa before they enter the cervix.
- B. Prevention of spermatozoa from entering the uterus.
- C. A change in vaginal pH from acidic to alkaline.
- D. Slowing of the movement of the migrating spermatozoa.
Correct Answer: A
Rationale: Spermicides destroy spermatozoa before they can enter the cervix, preventing fertilization.
A child diagnosed with tinea is being treated with griseofulvin (Grifulvin V). Which of the following instructions should the nurse give to the parents?
- A. Give the medication before a meal
- B. Have the child avoid intense sunlight
- C. Give the medication for 10 days
- D. Encourage increased fluid intake
Correct Answer: B
Rationale: Griseofulvin increases photosensitivity, so avoiding intense sunlight is critical. It is typically taken with food, requires weeks of treatment, and fluid intake is not specifically needed.
A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be an appropriate diversional activity for the nurse to encourage?
- A. Watching television with his roommate.
- B. Coloring picture books with his brother.
- C. Keeping up with his school work.
- D. Building a bird house.
Correct Answer: B
Rationale: Coloring is a quiet, bed-appropriate activity that engages a 10-year-old without physical exertion, suitable for rheumatic fever recovery.
A client has cystitis. The nurse should further assess the client for:
- A. Flank pain.
- B. Oliguria.
- C. Nausea and vomiting.
- D. Foul-smelling urine.
Correct Answer: D
Rationale: Foul-smelling urine is a common symptom of cystitis due to bacterial infection. Flank pain and oliguria are more indicative of pyelonephritis.