Nokea
A client with a history of heart failure is prescribed losartan (Cozaar). The nurse should monitor the client for which of the following side effects?
- A. Hyperkalemia.
- B. Hypoglycemia.
- C. Weight gain.
- D. Hypertension.
Correct Answer: A
Rationale: Losartan, an ARB, can cause hyperkalemia, requiring monitoring of potassium levels.
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A client with chronic obstructive pulmonary disease is bedridden at home and gets little exercise. The nurse should assess the client for which of the following?
- A. Increased sodium retention.
- B. Increased calcium excretion.
- C. Increased insulin use.
- D. Increased red blood cell production.
Correct Answer: B
Rationale: Prolonged immobility in COPD increases calcium excretion due to bone resorption, risking osteoporosis. The other options are not directly related to immobility.
A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make?
- A. Assess the patency of the Foley catheter
- B. Assess urine for excessive bleeding
- C. Assess urine for excessive bleeding
- D. Obtain a urine specimen for culture
Correct Answer: B
Rationale: Assessing for excessive bleeding post-cystoscopy with biopsy is critical due to the risk of hemorrhage. A Foley catheter may not be present, and culture is less urgent.
A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects?
- A. Gingival hyperplasia.
- B. Weight gain.
- C. Insomnia.
- D. Dry skin.
Correct Answer: A
Rationale: Phenytoin commonly causes gingival hyperplasia, which should be reported to manage oral health and adjust treatment if needed.
A client with a diagnosis of nephrotic syndrome states to the nurse, 'Why should I even bother trying to control my diet and the swelling? It doesn't really matter what I do if I can never get rid of this kidney problem anyway!' Which potential client problem should the nurse address based on the client's statement?
- A. Anxiety
- B. Difficulty coping
- C. Feeling powerless
- D. Negative body image
Correct Answer: C
Rationale: Feeling powerless is a problem when the client believes that personal actions will not affect an outcome in any significant way. Anxiety occurs when the client has a feeling of unease with a vague or undefined source. Difficulty coping indicates that the client has impaired adaptive abilities or behaviors in meeting the demands or roles expected from the individual. Negative body image occurs when the way the client perceives body image is altered.
A client tells the nurse that he is going to harm his brother-in-law, who called the police on him for threatening to hurt his ex-wife. The nurse should notify which of the following persons? Select all that apply.
- A. Agency administrators.
- B. Ex-wife.
- C. Police.
- D. Intended victim.
- E. Social service department.
Correct Answer: C,D
Rationale: The nurse has a duty to warn the intended victim (brother-in-law) and notify the police due to the credible threat of harm. Notifying administrators or social services may be secondary, and the ex-wife is not the current target.