Nokea
A client with a history of seizure disorder is admitted with complaints of breakthrough seizures. The nurse should give priority to:
- A. Administering anticonvulsants
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring respiratory rate
Correct Answer: A
Rationale: Administering anticonvulsants is the priority to control breakthrough seizures and prevent status epilepticus.
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A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:
- A. A rigid, boardlike abdomen
- B. Uterine atony
- C. A soft relaxed abdomen
- D. Hypertonicity of the uterus
Correct Answer: C
Rationale: A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.
The physician has ordered synthetic thyroid medication for a patient with hypothyroidism. The nurse should instruct the client to:
- A. Take the medication with food to prevent nausea
- B. Take the medication at bedtime
- C. Take the medication in the morning with water
- D. Take the medication with the evening meal
Correct Answer: C
Rationale: Thyroid medication (e.g. levothyroxine) is best taken in the morning on an empty stomach with water to optimize absorption and align with the body’s circadian rhythm. Taking it with food or at other times may reduce efficacy.
The nurse is caring for a client with a history of Addison’s disease. Which finding indicates a potential adrenal crisis?
- A. Blood pressure of 90/60 mmHg
- B. Weight gain of 2 pounds
- C. Serum sodium of 140 mEq/L
- D. Heart rate of 80 beats per minute
Correct Answer: A
Rationale: Adrenal crisis in Addison’s disease causes hypotension (e.g., 90/60 mmHg) due to cortisol and aldosterone deficiency, leading to shock. Weight gain, normal sodium, and normal heart rate are not indicative.
A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for what additional correlating wedge pressure data?
- A. A drop in blood pressure
- B. Rales on chest auscultation
- C. A temperature elevation
- D. Dry mucous membranes
Correct Answer: B
Rationale: PAWP of 14 mmHg is elevated, suggesting left ventricular overload. Rales (B) indicate pulmonary edema, correlating with high PAWP. BP drop (A), fever (C), and dry membranes (D) are unrelated.
The physician has prescribed Synthroid (levothyroxine) for a client with myxedema. Which statement indicates that the client understands the nurse's teaching regarding the medication?
- A. I will take the medication each morning after breakfast.
- B. I will check my heart rate before taking the medication.
- C. I will report visual disturbances to my doctor.
- D. I will stop the medication if I develop gastric upset.
Correct Answer: C
Rationale: Reporting visual disturbances is important, as levothyroxine can rarely cause visual changes, indicating a need for medical evaluation. It should be taken before breakfast, not stopped for gastric upset.