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A client with chronic pain is prescribed a fentanyl (Duragesic) patch. Which instruction should the nurse provide to the client?
- A. Apply the patch to a clean, dry, and hairless area of the skin.
- B. Use a heating pad over the patch to enhance absorption.
- C. Change the patch daily to maintain effectiveness.
- D. Place the patch on the same site with each application.
Correct Answer: A
Rationale: The correct answer is A. Applying the fentanyl patch to a clean, dry, and hairless area of the skin ensures proper absorption and effectiveness. Moisture, oils, and hair can interfere with absorption. Option B is incorrect as heating pads can increase drug absorption and lead to overdose. Option C is incorrect because fentanyl patches are usually changed every 72 hours, not daily. Option D is incorrect because rotating application sites helps prevent skin irritation and tolerance development.
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The healthcare provider is assessing a client with Cushing's syndrome. Which clinical manifestation should the healthcare provider expect to find?
- A. Hyperpigmentation of the skin.
- B. Hypotension.
- C. Moon face and buffalo hump.
- D. Weight loss.
Correct Answer: C
Rationale: The correct answer is C: Moon face and buffalo hump. In Cushing's syndrome, excessive cortisol production leads to characteristic symptoms like moon face (round, puffy face) and buffalo hump (fat accumulation at the back of the neck). This is due to redistribution of fat in the body. Hyperpigmentation (choice A) is seen in Addison's disease, not Cushing's. Hypotension (choice B) is unlikely due to the cortisol-induced sodium retention. Weight loss (choice D) is less common in Cushing's due to the metabolic changes causing weight gain.
A client with osteoporosis is being discharged home. Which instruction should the nurse include in the discharge teaching?
- A. Avoid weight-bearing exercises.
- B. Take calcium supplements with meals.
- C. Limit vitamin D intake.
- D. Increase intake of caffeine-containing beverages.
Correct Answer: B
Rationale: Correct Answer: B - Take calcium supplements with meals.
Rationale:
1. Calcium is essential for bone health and helps prevent osteoporosis.
2. Taking calcium with meals enhances absorption.
3. Adequate calcium intake is crucial for individuals with osteoporosis.
Summary:
A: Avoiding weight-bearing exercises is incorrect as they are beneficial for bone health.
C: Limiting vitamin D intake is incorrect as it is needed for calcium absorption.
D: Increasing caffeine intake is incorrect as it can decrease calcium absorption and worsen osteoporosis.
A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which side effect should the nurse monitor for?
- A. Hypertension
- B. Weight loss
- C. Hyperactivity
- D. Hyperglycemia
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Risperidone is an atypical antipsychotic medication known to cause metabolic side effects such as hyperglycemia. The nurse should monitor the client for signs and symptoms of high blood sugar levels, such as increased thirst, frequent urination, and fatigue. Hypertension (choice A) is not a common side effect of risperidone. Weight loss (choice B) is less likely as risperidone is associated with weight gain. Hyperactivity (choice C) is not a typical side effect of risperidone. Therefore, monitoring for hyperglycemia is essential in clients taking risperidone.
A client with a history of hypertension is prescribed lisinopril (Prinivil). Which side effect should the nurse monitor for?
- A. Dry cough.
- B. Weight gain.
- C. Tachycardia.
- D. Hyperglycemia.
Correct Answer: A
Rationale: The correct answer is A: Dry cough. Lisinopril, an ACE inhibitor, commonly causes a dry cough due to the accumulation of bradykinin. This side effect can be bothersome and non-productive. Other choices are incorrect because weight gain is not a common side effect of lisinopril but rather a side effect of some other antihypertensive medications. Tachycardia is not associated with lisinopril; in fact, it can cause bradycardia in some cases. Hyperglycemia is not a common side effect of lisinopril and is more commonly associated with other classes of antihypertensive medications.
When assessing a client with suspected meningitis, which finding is indicative of meningeal irritation?
- A. Brudzinski's sign
- B. Positive Babinski reflex
- C. Kernig's sign
- D. Both A and C
Correct Answer: D
Rationale: The correct answer is D, Both A and C. Brudzinski's sign and Kernig's sign are both indicative of meningeal irritation. Brudzinski's sign is when flexion of the neck causes involuntary flexion of the hip and knee. Kernig's sign is when there is resistance or pain with knee extension after hip flexion. These signs suggest inflammation of the meninges, commonly seen in meningitis. Babinski reflex (choice B) is not specific to meningitis and is related to upper motor neuron dysfunction. Therefore, the correct answer is D as it includes the two most relevant signs for meningeal irritation, while the other choices are not directly associated with this condition.