Nokea
A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?
- A. Holistic healing
- B. Spiritual advising
- C. Herbal preparations
- D. Witchcraft potions
Correct Answer: A
Rationale: Holistic healing. This traditional folk practitioner uses holistic methods for illnesses, often working with traditional health care providers.
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A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck.
- A. Which PRN medication should the nurse expect to give for a client with extrapyramidal side effects from perphenazine?
- B. Promazine (Sparine).
- C. Biperiden (Akineton).
- D. Thiothixene (Navane).
- E. Haloperidol (Haldol).
Correct Answer: B
Rationale: Biperiden, an antiparkinsonian agent, counteracts extrapyramidal side effects (e.g., dystonia, stiffness) caused by antipsychotics like perphenazine. Promazine, thiothixene, and haloperidol are antipsychotics that could worsen these side effects.
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
After determining the client's vital signs, which of the following activities should the nurse perform next?
- A. Position the client on her left side, supported with pillows.
- B. Check the chart and determine the status of the fluid balance from surgery.
- C. Check the client's abdominal dressing for any evidence of bleeding.
- D. Monitor the incision and pulmonary status for the presence of infection.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery
What are two major side effects of haloperidol (Haldol) the nurse should anticipate?
- A. Blood dyscrasia and extrapyramidal symptoms.
- B. Hearing loss and unsteady gait.
- C. Nystagmus and vertical gaze palsy.
- D. Alteration in level of consciousness and increased confusion.
Correct Answer: A
Rationale: major side effects of haloperidol (Haldol) include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS)
The nurse is caring for a client who had a total gastrectomy performed this morning. When the client returns to the nursing care unit, the drainage from the nasogastric tube is red. What is the nurse's best response to this?
- A. Report it immediately to the charge nurse or the physician
- B. Record the finding and continue to observe
- C. Immediately apply pressure to the operative site
- D. Place the client in Trendelenburg position
Correct Answer: A
Rationale: Red nasogastric drainage post-gastrectomy suggests bleeding, requiring immediate reporting to assess for hemorrhage.
A client admitted with tuberculosis asks the nurse how long he will have to take his prescription for INH. The best answer for the nurse to give the client is:
- A. It depends on the type of tuberculosis you have.'
- B. You will need to take the INH for approximately 6 months.'
- C. After about 6 weeks, the doctor will discontinue the medication.'
- D. You will remain on INH for an indefinite time period.'
Correct Answer: B
Rationale: INH (isoniazid) treatment for active tuberculosis typically lasts 6-9 months. Six weeks is too short, and indefinite treatment is incorrect.