Nokea
A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:
- A. Dissolves any clots already formed in the arteries
- B. Prevents the conversion of prothrombin to thrombin
- C. Interferes with the synthesis of vitamin K-dependent clotting factors
- D. Stimulates the manufacturing of platelets
Correct Answer: C
Rationale: Thrombolytic agents (e.g., streptokinase) directly activate plasminogen, dissolving fibrin deposits, which in turn dissolves clots that have already formed. Heparin prevents the formation of clots by potentiating the effects of antithrombin III and the conversion of prothrombin to thrombin. Warfarin prevents the formation of clots by interfering with the hepatic synthesis of the vitamin K-dependent clotting factors. Platelets initiate the coagulation of blood by adhering to each other and the site of injury to form platelet plugs.
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The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:
- A. Speaking and writing
- B. Comprehending spoken words
- C. Carrying out purposeful motor activity
- D. Recognizing and using an object correctly
Correct Answer: A
Rationale: Expressive aphasia (Broca’s aphasia) impairs the ability to speak and write due to damage in the frontal lobe’s speech center. Comprehension and motor activity are less affected.
The nurse is caring for a client with a history of cirrhosis. Which dietary restriction is most important?
- A. Low fat
- B. Low protein
- C. Low sodium
- D. Low carbohydrate
Correct Answer: C
Rationale: Low sodium is critical in cirrhosis to reduce fluid retention and ascites caused by portal hypertension and hypoalbuminemia. Protein is moderated but not severely restricted, and fat and carbohydrates are less critical.
On a mother's 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best position for the client to be placed in for this assessment is:
- A. Sims'
- B. Fowler's
- C. Prone
- D. Any position that the RN chooses
Correct Answer: A
Rationale: The Sims' position allows optimal exposure of the perineum and anus for assessment by raising the upper buttocks.
The pediatrician has diagnosed tinea capitis in an 8-year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
- A. Administer oral griseofulvin on an empty stomach for best results.
- B. Discontinue drug therapy if food tastes funny.
- C. May discontinue medication when the child experiences symptomatic relief.
- D. Observe for headaches, dizziness, and anorexia.
Correct Answer: D
Rationale: Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. The child may experience symptomatic relief after 48-96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician.
The client with cancer refuses to care for herself. Which action by the nurse would be best?
- A. Alternate nurses caring for the client so that the staff will not get tired of caring for this client.
- B. Talk to the client and explain the need for self-care.
- C. Explore the reason for the lack of motivation seen in the client.
- D. Talk to the physician about the client's lack of motivation.
Correct Answer: C
Rationale: Exploring the reason for the client’s refusal to self-care (e.g., depression, pain, or fear) is the best approach, as it addresses the underlying cause and guides interventions. Alternating nurses avoids the issue, explaining self-care may not address motivation, and consulting the physician is secondary.