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A client with a history of type 2 diabetes mellitus is prescribed exenatide (Byetta). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Pancreatitis.
- C. Hypertension.
- D. Weight gain.
Correct Answer: B
Rationale: Exenatide can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.
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A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation?
- A. Use a cool air vaporizer with plain water.
- B. Use saline nose drops and then a bulb syringe.
- C. Blow into the child's mouth to clear the infant's nose.
- D. Administer a nonprescription vasoconstrictive nose spray.
Correct Answer: B
Rationale: Saline nose drops followed by bulb syringe suction is safe and effective for clearing nasal congestion in infants. Vaporizers help with humidity, but saline and suction directly clear the nose.
The nurse is conducting health assessments for school-age children. A characteristic behavior of a 7-year-old girl is that she:
- A. Likes to play only with other girls.
- B. Prefers to play with her sister.
- C. Prefers to play team games.
- D. Likes to play alone.
Correct Answer: C
Rationale: At 7 years, children typically enjoy social interaction and team games, reflecting their developmental stage of cooperative play.
The nurse is delivering care to a client who is diagnosed with toxic shock syndrome (TSS). Which complication of this syndrome should the nurse monitor the client for?
- A. Pulmonary embolism
- B. Vitamin K deficiency
- C. Factor VIII deficiency
- D. Disseminated intravascular coagulopathy (DIC)
Correct Answer: D
Rationale: TSS is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this complication, and notifies the primary health care provider promptly if signs and symptoms are noted. The other options are not complications of TSS.
A client with antisocial personality disorder tells the nurse, 'I punched the guy out because he deserved it and then the cops arrested me.' Which of the following responses would be most helpful to the client?
- A. It's wrong to punch others.'
- B. If you punch people out, you'll get into trouble.'
- C. I wouldn't do that again if I were you.'
- D. Don't ever do that again; you're an adult.'
Correct Answer: B
Rationale: Explaining consequences (legal trouble) helps the client understand the impact of their actions, aligning with therapeutic communication for antisocial personality disorder.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after inhalation.
- C. Take the inhaler with meals.
- D. Stop the inhaler if dizziness occurs.
Correct Answer: B
Rationale: Rinsing the mouth after tiotropium inhalation prevents oral thrush.