Nokea
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Severe headache.
- D. Increased urine output.
Correct Answer: C
Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.
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A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions targeting which of the following problems?
- A. Drug and alcohol abuse.
- B. Risk for injury.
- C. Severe pain.
- D. Ineffective airway clearance.
Correct Answer: C
Rationale: Severe pain is a primary concern in acute pancreatitis, requiring targeted interventions like analgesics.
A client is taking 600 mg of valproic acid (Depakene) twice daily. The nurse should assess the client for which of the following? Select all that apply.
- A. Tremors.
- B. Hair loss.
- C. Gastrointestinal upset.
- D. Anorexia.
- E. Weight gain.
Correct Answer: A,C,E
Rationale: Valproic acid commonly causes tremors, gastrointestinal upset (e.g., nausea), and weight gain. Hair loss and anorexia are less common side effects.
When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?
- A. I need to stay out of the sunlight for 3 days.
- B. The injection site may itch, but I can scratch it if I need to.
- C. I need to avoid sexual intercourse for 2 to 3 days after the vaccination.
- D. I need to prevent becoming pregnant for 2 to 3 months after the vaccination.
Correct Answer: D
Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.
The nurse is assessing a client with a suspected cholecystitis. Which of the following findings is most indicative of this condition?
- A. Right upper quadrant pain.
- B. Left lower quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Right upper quadrant pain is a hallmark sign of cholecystitis due to gallbladder inflammation.
The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?
- A. Inappropriate laughter.
- B. An exaggerated sense of well-being.
- C. Slurring of words when excited.
- D. Visual hallucinations.
Correct Answer: B
Rationale: Euphoria in multiple sclerosis is characterized by an exaggerated sense of well-being, often disproportionate to the client's condition.