Nokea
A client with a panic disorder has a new prescription for Xanax (alprazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize?
- A. Short-term relief can be expected
- B. The medication acts as a stimulant
- C. Dosage will be increased as tolerated
Correct Answer: A
Rationale: Short-term relief can be expected. Xanax is a short-acting benzodiazepine useful in controlling panic symptoms quickly.
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An adult client has been medicated for elective surgery. The operating room nurse discovers that the consent form for surgery has not been signed. What should the nurse do?
- A. Have the client sign the consent form
- B. Tell the physician that the consent form has not been signed
- C. Have the client's spouse sign the consent form
- D. Continue preparation for surgery because the client has given implied consent
Correct Answer: B
Rationale: Preoperative medications impair judgment, making consent invalid post-administration. Notifying the physician ensures legal and ethical consent is obtained, delaying surgery if needed.
The nurse has reinforced teaching with a client who has rheumatoid arthritis and is receiving methotrexate. Which of the following statements by the client would require follow-up?
- A. I will avoid drinking alcoholic beverages while taking methotrexate.'
- B. I should take precautions to prevent pregnancy while taking methotrexate.'
- C. I should avoid large crowds and people who are ill while taking methotrexate.'
- D. I will avoid consuming foods high in folic acid that will decrease the effectiveness of methotrexate.'
Correct Answer: D
Rationale: Avoiding alcohol (A), preventing pregnancy (B), and avoiding crowds (C) are correct. Avoiding folic acid (D) is incorrect, as methotrexate often requires folic acid supplementation to reduce side effects.
The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse?
- A. Contraction duration of 95 seconds
- B. Contraction frequency of every 3 minutes
- C. Contraction intensity of 45 mm Hg
- D. Uterine resting tone of 10 mm Hg
Correct Answer: A
Rationale: Contraction duration of 95 seconds (A) is too long and may reduce fetal oxygenation, requiring intervention. Frequency (B), intensity (C), and resting tone (D) are within normal limits.
The nurse is discussing child safety with a group of mothers of toddlers. Which statement indicates a need for more instruction?
- A. My child should be in the back seat in a front-facing car seat.'
- B. My little one needs constant supervision.'
- C. My child eats finger foods.'
- D. I should put my medicines on a high shelf.'
Correct Answer: A
Rationale: Toddlers (under 2 years) should be in rear-facing car seats for safety; front-facing is incorrect, indicating a need for further instruction.
The practical nurse is assisting with care for several newborns in the nursery. Which of the following findings are abnormal and need to be reported to the registered nurse? Select all that apply.
- A. Chest wall retractions
- B. Flaking skin on the feet
- C. Head circumference of 13½ inches (34 cm)
- D. Jaundice of the head and sclera
- E. No documentation of voiding in past 24 hours
Correct Answer: A, D, E
Rationale: Chest retractions (A), jaundice (D), and no voiding (E) are abnormal and require reporting. Flaking skin (B) and head circumference (C) are normal for newborns.