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A nurse in a mental health facility is collecting data from a client taking lithium. Which of the following information should the nurse report to the provider as an indication of lithium toxicity?
- A. Dry cough
- B. Elevated blood pressure
- C. Stooped posture
- D. Slurred speech
Correct Answer: D
Rationale: The correct answer is D: Slurred speech. Lithium toxicity can manifest as neurological symptoms such as slurred speech due to its effects on the central nervous system. A dry cough (A) is not typically associated with lithium toxicity. Elevated blood pressure (B) may be a sign of other conditions but is not specific to lithium toxicity. Stooped posture (C) is more indicative of musculoskeletal issues rather than lithium toxicity. In summary, slurred speech is a key neurological symptom of lithium toxicity, making it the correct choice in this scenario.
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A nurse is caring for a client who is taking allopurinol. Which of the following laboratory findings indicates the medication has been effective?
- A. Decreased triglycerides
- B. Decreased uric acid
- C. Increased albumin
- D. Increased potassium
Correct Answer: B
Rationale: The correct answer is B: Decreased uric acid. Allopurinol is used to treat high levels of uric acid in the blood, which can lead to conditions like gout. A decrease in uric acid levels indicates that the medication is effectively lowering the client's uric acid levels. Triglycerides (choice A) are not directly affected by allopurinol. Albumin (choice C) and potassium (choice D) levels are not typically influenced by allopurinol therapy.
A nurse is reinforcing teaching about cyclosporine with a client who is postoperative following a kidney transplant. Which of the following statements indicates an understanding of the information?
- A. I can take ibuprofen to treat headaches.
- B. I will get out of bed slowly in the morning.
- C. I can expect hair loss when taking this medication.
- D. I will call my doctor if I have a sore throat.
Correct Answer: D
Rationale: The correct answer is D: "I will call my doctor if I have a sore throat." This statement indicates an understanding of the potential side effects of cyclosporine, one of which is immunosuppression leading to increased susceptibility to infections. By recognizing the importance of reporting a sore throat promptly, the client demonstrates awareness of the need for close monitoring and early intervention to prevent serious complications.
Incorrect choices:
A: Taking ibuprofen can interact with cyclosporine and is not recommended.
B: Getting out of bed slowly is a general precaution but not specific to cyclosporine.
C: Hair loss is not a common side effect of cyclosporine.
E, F, G: No information is provided for these choices.
A nurse is collecting data from a client who has been taking diazepam several times per day but recently ran out of the medication. Which of the following findings should the nurse recognize as a manifestation of withdrawal from diazepam?
- A. Tremors
- B. Anorexia
- C. Drowsiness
- D. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Tremors. Diazepam is a benzodiazepine used to treat anxiety and withdrawal symptoms. Withdrawal from diazepam can lead to physical symptoms such as tremors due to the sudden decrease in the drug's effects on the central nervous system. Tremors are a common manifestation of benzodiazepine withdrawal. Anorexia (choice B) is not typically associated with diazepam withdrawal. Drowsiness (choice C) is more likely a side effect of diazepam itself, not withdrawal. Hypotension (choice D) is not a common withdrawal symptom of diazepam.
A nurse is preparing to administer vaccines to an 11-year-old child who is up to date on immunizations. Which of the following vaccines should the nurse plan to administer?
- A. Quadrivalent human papillomavirus
- B. Rotavirus
- C. Pneumococcal conjugate
- D. Hepatitis B
Correct Answer: A
Rationale: The correct answer is A: Quadrivalent human papillomavirus vaccine. At age 11, the child should receive the HPV vaccine as part of routine immunization. HPV vaccination is recommended for both males and females at this age to prevent HPV-related cancers and diseases. The other options are not typically given to a child who is up to date on immunizations at age 11. Rotavirus vaccine is usually given in infancy, pneumococcal conjugate vaccine is given earlier in childhood, and hepatitis B vaccine is typically administered shortly after birth and during infancy. Therefore, the HPV vaccine is the appropriate choice for this scenario.
A nurse is reinforcing discharge teaching about sublingual nitroglycerin with a client who has angina. Which of the following statements indicates an understanding of the instructions?
- A. I understand that the medication can slow my heart rate.
- B. I am going to take the medication with food.
- C. I will take the medication every 10 minutes until the pain goes away.
- D. I should feel the effects of the medication within 5 minutes.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Nitroglycerin is a fast-acting medication used to relieve angina symptoms. Choosing option D shows understanding because nitroglycerin should provide relief within 5 minutes if the medication is effective. This rapid onset is crucial in managing acute angina attacks. Taking the medication every 10 minutes (C) could lead to overdose and severe side effects. Slow heart rate (A) is not a common side effect of nitroglycerin. Taking with food (B) may delay absorption and reduce effectiveness.