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A client with newly diagnosed hypertension is prescribed enalapril (Vasotec). Which instruction should the nurse provide to the client?
- A. Increase your intake of potassium-rich foods.
- B. Report any persistent cough to your healthcare provider.
- C. Take the medication with a full meal.
- D. Avoid grapefruit juice while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: Report any persistent cough to your healthcare provider. Enalapril is an ACE inhibitor that can cause a dry, persistent cough as a side effect. This cough can be a sign of a serious condition called angioedema. Therefore, it is crucial for the client to report any cough to their healthcare provider promptly to assess and manage it.
Incorrect choices:
A: Increasing intake of potassium-rich foods is not necessary when taking enalapril, as it does not typically cause potassium imbalances.
C: Enalapril can be taken with or without food, so taking it with a full meal is not a specific instruction.
D: Avoiding grapefruit juice is typically recommended for medications metabolized by the CYP3A4 enzyme, which enalapril is not.
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An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?
- A. This behavior can be considered sexual harassment and should be reported to the administration immediately.
- B. The UAP should be reassigned to another group of residents, preferably females only.
- C. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need.
- D. The resident needs to understand the rules regarding unwanted touching of the staff and the consequences.
Correct Answer: C
Rationale: The correct answer is C because the behavior exhibited by the resident may stem from touch deprivation rather than being intentional sexual harassment. Here's a step-by-step rationale:
1. Understanding the resident's age and environment (extended care facility) helps in interpreting his behavior.
2. The resident's actions suggest a need for touch, which is common in older adults who may lack physical contact.
3. Educating the resident on appropriate ways to express his need for touch can address the underlying issue.
4. Reassigning the UAP or reporting the incident as sexual harassment (options A and B) may not address the root cause of the behavior and could potentially harm the resident's well-being.
In summary, choice C focuses on addressing the resident's potential touch deprivation in a compassionate and understanding manner, making it the best assessment of the situation.
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 severe anemia is being treated with a blood transfusion. Which assessment finding indicates a transfusion reaction?
- A. Elevated blood pressure.
- B. Fever and chills.
- C. Increased urine output.
- D. Bradycardia.
Correct Answer: B
Rationale: The correct answer is B: Fever and chills. This indicates a transfusion reaction because it is a common symptom of hemolytic reactions, where the body is reacting to incompatible blood. Elevated blood pressure (A) is not typically a sign of a transfusion reaction. Increased urine output (C) is more likely a sign of fluid overload. Bradycardia (D) is not a common symptom of a transfusion reaction. Fever and chills are classic signs of a transfusion reaction due to the body's immune response to the blood transfusion.
A client with chronic kidney disease is prescribed a low-protein diet. Which laboratory result should the nurse monitor to evaluate the effectiveness of the diet?
- A. Blood urea nitrogen (BUN)
- B. Serum potassium
- C. Serum calcium
- D. Creatinine clearance
Correct Answer: A
Rationale: The correct answer is A: Blood urea nitrogen (BUN). BUN is a waste product that reflects protein intake and kidney function. In chronic kidney disease, high protein intake can increase BUN levels, so monitoring BUN helps assess the effectiveness of the low-protein diet.
Incorrect choices:
B: Serum potassium - This is more related to kidney function but not specifically affected by a low-protein diet.
C: Serum calcium - Calcium levels are not directly affected by protein intake or a low-protein diet in chronic kidney disease.
D: Creatinine clearance - This measures kidney function but is not directly influenced by protein intake.
A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to assess the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Platelet count
- C. Activated partial thromboplastin time (aPTT)
- D. International normalized ratio (INR)
Correct Answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). The aPTT measures the effectiveness of heparin therapy by assessing the clotting time. In patients with DVT receiving heparin, the goal is to keep the aPTT within a therapeutic range to prevent clot formation. Monitoring aPTT helps ensure the dose of heparin is appropriate.
Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to monitor for heparin-induced thrombocytopenia but does not directly assess the effectiveness of heparin therapy for DVT.