Nokea
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.
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The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should monitor the client for which of the following adverse effects?
- A. Endometrial cancer.
- B. Hypocalcemia.
- C. Alopecia.
- D. Weight loss.
Correct Answer: A
Rationale: Tamoxifen increases the risk of endometrial cancer, requiring monitoring for abnormal vaginal bleeding.
A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first?
- A. Institute droplet precautions.
- B. Obtain the child's vital signs.
- C. Ask the parent about medication allergies.
- D. Inquire about the health of siblings at home.
Correct Answer: A
Rationale: Meningococcal meningitis is transmitted via droplets, so instituting precautions is the priority to prevent spread.
On the first postpartum day, the nurse is caring for a primiparous client who has recently emigrated from Japan to the United States and speaks only a little English. The nurse observes that the client has been bottle-feeding her neonate on occasion, but most of the neonatal care is being performed by the client's mother-in-law. Which of the following actions would be most appropriate?
- A. Notify the social worker because bonding may be affected.
- B. Document the unusual maternal behavior in the client's chart.
- C. Determine whether this is a cultural practice for the client and her family.
- D. Obtain an order to make a home visit after the client's discharge.
Correct Answer: C
Rationale: Assessing whether the mother-in-law's involvement is a cultural practice respects the client's background and avoids misjudging normal family dynamics.
A client is reporting skin irritation from the edges of a cast that was applied the previous day. The nurse notes that the skin is pink and irritated. Which corrective action should the nurse take?
- A. Petal the edges of the cast with tape.
- B. Massage the skin at the rim of the cast.
- C. Shake a small amount of powder under the cast rim.
- D. Use a hair dryer set on a cool high setting to soothe the irritation.
Correct Answer: A
Rationale: The nurse should petal the edges of the cast with tape to minimize skin irritation. Massaging the skin will not help the problem. Powder should not be shaken under the cast because it could clump, become moist, and cause skin breakdown. A hair dryer is used on a cool low setting if a nonplaster cast becomes wet or if the client's skin itches under a cast.
The nurse provides instructions to a client who is taking allopurinol for the treatment of gout. Which statement by the client indicates an understanding of the medication?
- A. I should put ice on my lips if they swell.
- B. I need to take the medication 2 hours after I eat.
- C. I need to drink at least 8 glasses of liquids every day.
- D. I can use an antihistamine lotion if I get a rash that is itchy.
Correct Answer: C
Rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. If the client develops a rash, irritation of the eyes, or swelling of the lips or mouth, he or she should contact the primary health care provider because this may indicate hypersensitivity. Allopurinol is to be given with or immediately after meals or milk.