Nokea
A client with a history of type 2 diabetes mellitus is prescribed liraglutide (Victoza). 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: Liraglutide can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.
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After teaching the parents of a toddler about appropriate snack foods for their child, the nurse judges that the instructions about not giving the child raisins for snacks are effective when the father states should be following?
- A. Raisins are low in nutritional value
- B. Raisins are easy to choke on
- C. Raisins can increase tooth decay
- D. Raisins are hard to digest entirely
Correct Answer: B
Rationale: Raisins are a choking hazard for toddlers due to their size and texture, making this the correct reason to avoid them. Nutritional value, tooth decay, and digestion are less relevant concerns.
A female client with infertility related to anovulatory cycles is prescribed menotropins (Pergonal). Which of the following, if stated by the client as a possible adverse effect of this medication, indicates successful teaching?
- A. Pulmonary edema.
- B. Ovarian enlargement.
- C. Visual disturbances.
- D. Breast tenderness.
Correct Answer: B
Rationale: Menotropins stimulate ovarian follicle growth, which can lead to ovarian enlargement as a common adverse effect. Pulmonary edema, visual disturbances, and breast tenderness are not typically associated with this medication.
A client with a history of asthma is prescribed montelukast (Singulair). The nurse should explain that this medication works by:
- A. Dilating the bronchioles.
- B. Reducing airway inflammation.
- C. Thinning mucus secretions.
- D. Suppressing the cough reflex.
Correct Answer: B
Rationale: Montelukast, a leukotriene inhibitor, reduces airway inflammation in asthma, preventing symptoms.
The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following recommendations is most effective in reducing blood pressure?
- A. Increasing dietary potassium intake.
- B. Reducing daily sodium intake.
- C. Drinking one glass of red wine daily.
- D. Taking a daily multivitamin.
Correct Answer: B
Rationale: Reducing sodium intake is highly effective in lowering blood pressure by decreasing fluid retention and vascular resistance.
During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?
- A. Assist the client with finding safe ways to express her anger.
- B. Talk with the client about confronting her uncle and cousin directly.
- C. Defer talking about the abuse to prevent further self-mutilation.
- D. Discuss the possibility of the client suing her relatives for their abuse.
Correct Answer: A
Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.