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A nurse is assessing a patient who has schizophrenia and is taking aripiprazole. The nurse should notify the provider of which of the following findings? Which finding should the nurse report for aripiprazole?
- A. Constipation
- B. Weight gain of 5 lb in 1 month
- C. Insomnia
- D. Muscle stiffness
Correct Answer: D
Rationale: The correct answer is D: Muscle stiffness. Aripiprazole is an atypical antipsychotic that can cause extrapyramidal symptoms, including muscle stiffness. This side effect can be a sign of a serious condition called neuroleptic malignant syndrome. The nurse should report this finding promptly to the provider for further evaluation and management. Constipation (A), weight gain (B), and insomnia (C) are common side effects of aripiprazole but are not as urgent or indicative of a potentially serious condition compared to muscle stiffness.
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A nurse is caring for a patient who is postoperative following abdominal surgery. The nurse discovers a loop of bowel protruding through an opening in the surgical incision. What should the nurse do? What should the nurse do for a protruding bowel?
- A. Gently reinsert the bowel back into the patient's wound.
- B. Place the head of the patient's bed in the flat position.
- C. Apply moistened sterile gauze to the site.
- D. Position the patient on his left side.
Correct Answer: C
Rationale: The correct answer is C: Apply moistened sterile gauze to the site. This is the correct action because it helps to keep the exposed bowel moist, which is crucial to prevent drying and potential damage. Reinserting the bowel (choice A) may cause further harm and should only be done by a surgeon. Placing the head of the bed flat (choice B) can increase intra-abdominal pressure and worsen the situation. Positioning the patient on his left side (choice D) does not address the immediate need to protect the exposed bowel. Applying moistened gauze is the best initial action to protect the bowel while awaiting further medical intervention.
A nurse in the emergency department is attending to a patient exhibiting symptoms of a myocardial infarction. Which of the following actions should the nurse prioritize? Which action should the nurse prioritize for myocardial infarction?
- A. Initiate oxygen therapy.
- B. Obtain a blood sample.
- C. Attach the leads for a 12-lead ECG.
- D. Insert an IV catheter.
Correct Answer: A
Rationale: The correct answer is A: Initiate oxygen therapy. In a myocardial infarction, the priority is to ensure adequate oxygen supply to the heart muscle to prevent further damage. Oxygen therapy helps increase oxygen delivery to the heart, reducing the workload on the heart muscle. This action can potentially limit the size of the infarction and improve the patient's outcome. Obtaining a blood sample (B) can provide valuable information but is not as urgent as ensuring oxygen supply. Attaching leads for a 12-lead ECG (C) is important for diagnosing the myocardial infarction but does not directly address the immediate need for oxygen. Inserting an IV catheter (D) may be necessary for administering medications, but oxygen therapy takes precedence in this situation.
A nurse is assessing a 1-year-old child. Which of the following disorders should the nurse suspect? Which disorder should the nurse suspect in a 1-year-old?
- A. Intussusception.
- B. Wilms tumor.
- C. Pyloric stenosis.
- D. Nephritic syndrome.
Correct Answer: B
Rationale: The correct answer is B: Wilms tumor. This is because Wilms tumor is a common childhood kidney cancer that typically presents in children aged 1-5 years. The nurse should suspect Wilms tumor in a 1-year-old child due to the age range of presentation. Intussusception (A) is more common in infants aged 3-12 months. Pyloric stenosis (C) typically presents in infants around 2-8 weeks old. Nephritic syndrome (D) is more common in older children. Therefore, based on the age group and common presentation, Wilms tumor is the most likely disorder to suspect in a 1-year-old child.
A nurse is caring for a patient who is postoperative following a knee arthroscopy. Which of the following actions should the nurse take? Which action should the nurse take post-knee arthroscopy?
- A. Apply a warm compress to the surgical site.
- B. Keep the leg in a dependent position.
- C. Encourage weight-bearing immediately.
- D. Elevate the affected leg.
Correct Answer: D
Rationale: The correct action is to elevate the affected leg post-knee arthroscopy. Elevating the leg helps reduce swelling and promote circulation, aiding in the healing process. Keeping the leg in a dependent position (choice B) can increase swelling. Applying a warm compress (choice A) may also increase swelling. Encouraging weight-bearing immediately (choice C) can put stress on the surgical site and delay healing. Thus, elevating the affected leg is the most appropriate action in this scenario.
A nurse is providing teaching to a patient who has stable angina and a new prescription for nitroglycerin oral, sustained-release capsules. Which of the following instructions should the nurse give? What instructions should the nurse give for nitroglycerin capsules?
- A. Take one capsule at the onset of anginal pain.
- B. Take the medication with meals.
- C. Stop taking the medication if side effects are troublesome.
- D. Swallow the capsules whole.
Correct Answer: D
Rationale: The correct answer is D: Swallow the capsules whole. Nitroglycerin oral, sustained-release capsules should be swallowed whole without crushing or chewing to ensure the medication is released slowly over time. If the capsules are broken or chewed, the full dose may be released at once, leading to a rapid drop in blood pressure. Choice A is incorrect because nitroglycerin capsules are not meant to be taken at the onset of pain, but as a preventive measure. Choice B is incorrect as there is no specific instruction to take the medication with meals. Choice C is incorrect as stopping medication abruptly can be dangerous, and patients should consult their healthcare provider before making any changes.