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A client with a history of hypertension is taking a beta-blocker. Which side effect should the LPN/LVN monitor for in this client?
- A. Increased appetite
- B. Dry mouth
- C. Bradycardia
- D. Insomnia
Correct Answer: C
Rationale: The correct answer is C: Bradycardia. Beta-blockers are medications that can lower heart rate, leading to bradycardia as a potential side effect. It is essential for the LPN/LVN to monitor for this adverse effect due to the medication's mechanism of action. Choices A, B, and D are incorrect because increased appetite, dry mouth, and insomnia are not typically associated with beta-blocker use. Monitoring for bradycardia is crucial to ensure patient safety and to prevent any potential complications.
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In a mass casualty scenario at a child day care center, which child would the triage nurse prioritize for treatment last?
- A. An infant with intermittent bulging anterior fontanel between crying episodes
- B. A toddler with severe deep abrasions covering over 98% of the body
- C. A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
- D. A school-age child with singed eyebrows and hair on the arms
Correct Answer: B
Rationale: In a mass casualty scenario, the triage nurse would prioritize the toddler with severe deep abrasions covering over 98% of the body for treatment last. This child is categorized as 'expectant' due to the extensive injuries, which are unlikely to be survivable even with immediate treatment. The other choices describe injuries that are serious but have a higher likelihood of survival with appropriate and timely intervention. The infant with an intermittent bulging anterior fontanel may have increased intracranial pressure requiring urgent evaluation, the preschooler with leg fractures can be stabilized and treated effectively, and the school-age child with singed hair likely has superficial burns which can be managed promptly.
The patient refuses a morning bath, stating a preference for evening baths. What is the best action for the nurse to take?
- A. Defer the bath until evening and pass on the information to the next shift.
- B. Tell the patient that daily morning baths are the 'normal' routine.
- C. Explain the importance of maintaining morning hygiene practices.
- D. Cancel hygiene for the day and attempt again in the morning.
Correct Answer: A
Rationale: The best action for the nurse is to respect the patient's preference and autonomy. By deferring the bath until evening, the nurse acknowledges and accommodates the patient's routine, promoting patient-centered care. Choice B could be seen as dismissive of the patient's preference and may not foster a therapeutic relationship. Choice C, while important, doesn't address the patient's current refusal. Choice D is not respectful of the patient's autonomy and could lead to increased resistance. Therefore, option A is the most appropriate and patient-centered approach.
A client with amphetamine toxicity and sensory overload is being cared for by a nurse. Which intervention should the nurse implement?
- A. Immediately conduct a thorough assessment.
- B. Encourage visitors to distract the client.
- C. Provide a private room and limit stimulation.
- D. Speak softly to the client.
Correct Answer: C
Rationale: The most appropriate intervention for a client with amphetamine toxicity and sensory overload is to provide a private room and limit stimulation. This approach helps reduce external stimuli, which can exacerbate sensory overload, and creates a calming environment for the client. Encouraging visitors to distract the client may worsen sensory overload by adding more stimulation. Speaking softly, rather than at a higher volume, is more suitable to help maintain a calm environment. Therefore, the correct choice is to provide a private room and limit stimulation (option C) in this scenario.
A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching?
- A. "Our child wants to eat as much as we do, but we're afraid it will lead to becoming overweight."
- B. "Our child skips lunch sometimes, but we figure it's okay as long as we eat a healthy breakfast and dinner."
- C. "We limit fast-food restaurant meals to three times a week now."
- D. "We reward school achievements with a point system instead of pizza or ice cream."
Correct Answer: D
Rationale: The correct answer is D. Rewarding school achievements with a point system rather than food items like pizza or ice cream is a healthier approach. This choice indicates an understanding of the teaching about nutrition and the importance of not using food as a reward. Choices A, B, and C do not demonstrate a clear understanding of the teaching as they focus on concerns about overeating, skipping meals, and limiting fast-food consumption but do not address the concept of avoiding food rewards for achievements.
A nurse is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
- A. Use the complete name of the medication magnesium sulfate
- B. Maintain the space between the numerical dose and the unit of measure
- C. Note the dosage of insulin in units
- D. Use 'subcut' for indicating a subcutaneous injection
Correct Answer: A
Rationale: The correct answer is A. The Institute for Safe Medication Practices recommends using the complete medication name magnesium sulfate when documenting medications to prevent misinterpretation. Choice B is incorrect because spaces should be maintained between the numerical dose and unit of measure for clarity. Choice C is incorrect as the standard notation for insulin dosage is in units, not using the letter U. Choice D is incorrect as the abbreviation for subcutaneous injection is commonly written as 'subcut' or 'subcutaneous,' not as SC.