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A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse plan to administer?
- A. Lorazepam
- B. Atenolol
- C. Naltrexone
- D. Methadone
Correct Answer: A
Rationale: Lorazepam is the correct choice for managing acute alcohol withdrawal symptoms due to its effectiveness in controlling agitation and tremors associated with this condition. Atenolol (Choice B) is a beta-blocker mainly used for hypertension and angina, not for alcohol withdrawal symptoms. Naltrexone (Choice C) is used for alcohol dependence treatment by reducing cravings and the rewarding effects of alcohol, but it is not typically used in acute withdrawal situations. Methadone (Choice D) is an opioid agonist mainly used for opioid detoxification and maintenance therapy, not for alcohol withdrawal.
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A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?
- A. Decreased level of consciousness
- B. Inability to identify common objects
- C. Poor problem-solving ability
- D. Preoccupation with somatic disturbances
Correct Answer: B
Rationale: In schizophrenia, clients often display an inability to identify common objects due to cognitive impairment. This is known as associative agnosia, where individuals struggle to recognize familiar objects, faces, or sounds. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head trauma or drug overdose. Poor problem-solving ability may be seen in various mental health disorders but is not specific to schizophrenia. Preoccupation with somatic disturbances is more commonly seen in somatic symptom disorders or somatic delusions, not a typical finding in schizophrenia.
A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?
- A. Serum potassium level of 4.2 mEq/L
- B. Blood pressure of 138/84 mm Hg
- C. Platelet count of 150,000/mm³
- D. INR of 2.0
Correct Answer: D
Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.
A client with a new diagnosis of hypertension is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should avoid eating foods high in potassium.
- B. I will check my blood pressure at least once a week.
- C. I should increase my intake of dairy products.
- D. I should exercise for 30 minutes at least 5 days a week.
Correct Answer: D
Rationale: The correct answer is D. Exercising for 30 minutes at least 5 days a week helps manage hypertension by promoting cardiovascular health. Statements A, B, and C are incorrect. Avoiding foods high in potassium is not necessary unless specifically advised by a healthcare provider. Checking blood pressure once a week is not frequent enough for effective monitoring. Increasing dairy product intake is not a recommended approach to managing hypertension.
A nurse is caring for a client who is receiving radiation therapy. Which of the following findings should the nurse expect?
- A. Weight gain
- B. Mouth sores
- C. Hyperpigmentation
- D. Increased saliva production
Correct Answer: B
Rationale: The correct answer is B: Mouth sores. Mouth sores are a common side effect of radiation therapy, especially when the treatment is focused on the head or neck area. Weight gain is not typically associated with radiation therapy; instead, clients may experience weight loss due to side effects like nausea and loss of appetite. Hyperpigmentation is not a common finding related to radiation therapy. Increased saliva production is not a typical side effect of radiation therapy; instead, clients may experience dry mouth.
A client is receiving discharge teaching regarding a new prescription for warfarin. Which of the following statements by the client indicates a need for further teaching?
- A. I will eat more leafy green vegetables while taking warfarin.
- B. I will have my INR checked regularly while taking warfarin.
- C. I will avoid drinking grapefruit juice while taking warfarin.
- D. I will use a soft toothbrush while taking warfarin.
Correct Answer: A
Rationale: The correct answer is A. Clients taking warfarin should avoid leafy green vegetables as they are high in vitamin K, which can reduce the effectiveness of the medication. Therefore, the statement 'I will eat more leafy green vegetables while taking warfarin' indicates a need for further teaching. Choice B is correct as regular monitoring of INR levels is necessary for clients on warfarin. Choice C is correct as grapefruit juice can interact with warfarin and should be avoided. Choice D is correct as using a soft toothbrush is recommended to prevent gum bleeding while on warfarin.