Nokea
A client with acquired immunodeficiency syndrome (AIDS) is admitted because of paranoia and visual hallucinations probably related to progressive dementia. The client continues to be restless and have hallucinations. The nurse calls the physician, and after explaining the situation, background, and assessment recommends that the physician consider writing an order to the client to have:
- A. Methylphenidate (Ritalin).
- B. Lorazepam (Ativan).
- C. Nefazodone (Serzone).
- D. Sertraline (Zoloft).
Correct Answer: B
Rationale: Lorazepam can help manage acute agitation and restlessness in a client with AIDS-related dementia.
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Which of the following compensatory actions by the body would occur if a client were in respiratory acidosis?
- A. Excretion of bicarbonate (HCO₃⁻) by the kidneys.
- B. Retention of HCO₃⁻ by the kidneys.
- C. Increase in respiratory rate by the lungs.
- D. Decrease in respiratory rate by the lungs.
Correct Answer: B, C
Rationale: In respiratory acidosis, the body compensates by retaining bicarbonate (HCO₃⁻) in the kidneys and increasing respiratory rate to eliminate excess CO2.
The nurse is teaching a client with a new diagnosis of epilepsy about driving restrictions. Which of the following instructions is most appropriate?
- A. You can drive after being seizure-free for 6 months.
- B. You can drive if you take your medication regularly.
- C. You can drive with a passenger at all times.
- D. You can drive during the daytime only.
Correct Answer: A
Rationale: Most regions require a client to be seizure-free for 6 months before driving, ensuring safety.
The nurse is teaching a client about the use of a transdermal nicotine patch for smoking cessation. Which instruction is correct?
- A. Apply it to the same site daily
- B. Remove it at night
- C. Keep it on during showers
- D. Apply it to the face
Correct Answer: B
Rationale: Removing the nicotine patch at night reduces the risk of side effects like insomnia and allows a nicotine-free period.
The nurse is evaluating a weight-reduction plan designed for an obese client. Which statement by the client indicates the need for further teaching?
- A. It is so difficult to find food exchanges that taste good and fill me up.
- B. This diet doesn't let me go out for lunch with my friends at work anymore.
- C. I wish my mother could have seen me lose the 60 pounds in the last 9 months.
- D. My wife was kidding me the other night about my being a whole new husband.
Correct Answer: B
Rationale: Option 2 indicates that the client may be having difficulty in making appropriate dietary choices when going out for lunch or that he may perceive that his coworkers are uncomfortable with his need to eat differently. A sense of not fitting in can leave the obese individual isolated and therefore make it more difficult for him to maintain his diet at work. In the absence of other data, option 1 is a normal response to the changes in eating habits. Options 3 and 4 are responses indicating a positive perception of self; that is, another person has recognized these changes, and the client wishes to have been able to share these changes with his mother.
A 10-year-old child has the following blood glucose readings during a 24-hour period. Which reading requires the most immediate intervention?
- A. 50 mg/dL.
- B. 100 mg/dL.
- C. 150 mg/dL.
- D. 200 mg/dL.
Correct Answer: A
Rationale: A blood glucose of 50 mg/dL indicates hypoglycemia, requiring immediate intervention to prevent neurological complications.