Nokea
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
- A. The parts of a system are only minimally related.
- B. Dysfunction in one part affects every other part.
- C. A family system has no boundaries.
- D. Healthy families are enmeshed.
Correct Answer: B
Rationale: Any change in any part of the system affects all other parts.
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A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- A. 5-10 mcg/mL
- B. 10-25 mcg/mL
- C. 25-40 mcg/mL
- D. 40-60 mcg/mL
Correct Answer: B
Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring effective treatment of infections while minimizing toxicity risks.
The nurse is caring for a client with a history of myasthenia gravis. Which medication should the nurse anticipate being prescribed?
- A. Pyridostigmine (Mestinon)
- B. Phenytoin (Dilantin)
- C. Propranolol (Inderal)
- D. Methotrexate (Rheumatrex)
Correct Answer: A
Rationale: Pyridostigmine, a cholinesterase inhibitor, is used to treat myasthenia gravis by improving neuromuscular transmission. The other medications are for seizures, hypertension, or arthritis, not myasthenia.
A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:
- A. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids
- B. Is available at discount pharmacies for a reduced price
- C. Is usually not necessary after the first year following transplantation
- D. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually resolve themselves
Correct Answer: A
Rationale: Cyclosporine is the immunosuppressive drug of choice. It provides immunosuppression but does not lower the white blood cell count; therefore, the client is less susceptible to infection. Cyclosporine is available at discount pharmacies. The cost may be absorbed by health insurance, or Medicare, if the client is eligible. However, this statement does not address the entire problem verbalized by the client. Immunosuppressive agents will be taken for the client's entire life because rejection can occur at any time. These side effects do not necessarily resolve in time; however, the client may adapt.
The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:
- A. Give her a small soft blanket to hold
- B. Give her good perineal care after each diaper change
- C. Leave the door open to her room
- D. Pick her up when she cries
Correct Answer: D
Rationale: A soft blanket may be comforting, but it is not directed toward developing a sense of trust. Good perineal care is important, but it is not directed toward developing a sense of trust. An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. Consistently picking her up when she cries will help the child feel trust in her caregivers.
A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time?
- A. Give the injection in the vastus lateralis site before the child awakens.
- B. Awaken the child first and give the injection in the ventrogluteal site.
- C. Awaken the child first and give the injection in the dorsogluteal site.
- D. Ask the mother to place the child on the examination table and leave the room, and then give the injection in an appropriate site.
Correct Answer: B
Rationale: If awakened first, the child will know that nothing painful will be done without the child being alerted. The ventrogluteal site is a safe site for children because it is a large muscle free of major nerves and blood vessels. The dorsogluteal site is not recommended in children who have not been walking for at least 1 year because the muscle is not fully developed. The parent will be able to offer support and comfort during and after the injection.