Nokea
A client with an acute attack of gout is started on colchicines (Colorys). She should be instructed to report which of the following symptoms?
- A. Diarrhea
- B. Headache
- C. Itching
- D. Fever
Correct Answer: A
Rationale: Colchicine commonly causes diarrhea, which should be reported to prevent dehydration or other complications.
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The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired all the time.
- B. I have trouble sleeping at night.
- C. I think about hurting myself sometimes.
- D. I have a dry mouth.
Correct Answer: C
Rationale: Thoughts of self-harm indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on sertraline. Options A, B, and D are common side effects of SSRIs (fatigue, insomnia, dry mouth) and less urgent.
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
The nurse would be MOST concerned by which of the following?
- A. A CVP reading of 12 and bradycardia.
- B. Tachycardia and hypotension.
- C. Dyspnea and oliguria.
- D. Rales and tachycardia.
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload
A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following?
- A. Hyperactive deep tendon reflexes.
- B. Peripheral neuropathy affecting the hands.
- C. Disorientation to person, place, and time.
- D. Impaired concentration and memory loss.
Correct Answer: C
Rationale: approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation
The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's
- A. poor nutritional status
- B. decreased gastrointestinal motility
- C. increased splanchnic blood flow
- D. altered peripheral resistance
Correct Answer: B
Rationale: Decreased gastrointestinal motility, together with shrinkage of the gastric mucosa and changes in hydrochloric acid levels, will decrease absorption of medications and interfere with their actions.
A client arrives at the emergency room with an HR of 120, an RR of 48, and hemoptysis. The nurse should give priority to:
- A. Obtaining a history of the current illness
- B. Applying oxygen via mask
- C. Obtaining additional vital signs
- D. Checking arterial blood gases
Correct Answer: B
Rationale: Hemoptysis and tachypnea suggest respiratory distress, so oxygen administration is the priority to stabilize the client.