Nokea
A client with a history of schizophrenia is prescribed aripiprazole (Abilify). The nurse should monitor the client for which of the following adverse effects?
- A. Akathisia.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Aripiprazole can cause akathisia, a movement disorder, requiring monitoring.
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A client with a history of chronic kidney disease is prescribed calcitriol (Rocaltrol). The nurse should explain that this medication works by:
- A. Reducing blood pressure.
- B. Increasing calcium absorption.
- C. Decreasing phosphate levels.
- D. Increasing urine output.
Correct Answer: B
Rationale: Calcitriol, a vitamin D analog, increases calcium absorption in chronic kidney disease to correct hypocalcemia.
A client with acute myocardial infarction receives therapy with alteplase. Which finding indicates to the nurse that the client is experiencing a possible complication?
- A. Epistaxis
- B. Vomiting
- C. ECG changes
- D. Absent pedal pulses
Correct Answer: A
Rationale: Bleeding is an adverse effect of altepase therapy. The bleeding can be superficial or internal and can be spontaneous. None of the remaining options are side or adverse effects of altepase therapy.
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when the nurse is
- A. I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: A
Rationale: Suspecting a bladder infection requires immediate medical evaluation, not just a visit to the obstetrician, as infections can trigger preterm labor. The other statements reflect correct understanding of preterm labor management.
The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
- A. Widening pulse pressure
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.
When a client of Mexican American descent tells the nurse that she treated her infection by drinking milk, the nurse interprets the client's remark as:
- A. Confusion from fever
- B. Use of the first disease concept
- C. Use of milk as a laxative
- D. The need for a dietitian to assist her with meal planning
Correct Answer: B
Rationale: In Mexican American culture, milk may be used as a traditional remedy for certain conditions, reflecting the ‘hot-cold' disease concept. It's not necessarily confusion, a laxative, or a dietary issue.