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A nurse is caring for a patient who has had a myocardial infarction. Which of the following medications should the nurse expect to be prescribed for this patient?
- A. Lisinopril.
- B. Acetaminophen.
- C. Furosemide.
- D. Hydrochlorothiazide.
Correct Answer: A
Rationale: Step 1: Lisinopril is an ACE inhibitor commonly prescribed post-myocardial infarction to reduce strain on the heart and prevent further damage.
Step 2: ACE inhibitors like Lisinopril help lower blood pressure and improve heart function.
Step 3: By reducing the workload on the heart, Lisinopril can help prevent complications post-MI.
Step 4: Acetaminophen (B) is a pain reliever and does not address the cardiovascular issues post-MI.
Step 5: Furosemide (C) and Hydrochlorothiazide (D) are diuretics typically used for managing fluid retention, not the primary focus after an MI.
Summary: Lisinopril is the correct choice as it helps improve heart function and prevent complications post-MI, unlike the other options which do not directly address the cardiovascular issues associated with MI.
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A nurse is caring for a patient who is receiving chemotherapy. The nurse should monitor for signs of which of the following complications?
- A. Anemia.
- B. Hyperkalemia.
- C. Neutropenia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Neutropenia. Chemotherapy can suppress bone marrow function, leading to a decrease in neutrophils (a type of white blood cell), causing neutropenia. This increases the risk of infection. Monitoring for signs of infection is crucial in patients receiving chemotherapy to prevent serious complications. Anemia (A) is a common side effect of chemotherapy but is not directly related to infection risk. Hyperkalemia (B) and hypocalcemia (D) are less likely to be immediate complications of chemotherapy compared to neutropenia.
Which condition places a client at risk for elevated ammonia levels?
- A. Renal failure
- B. Cirrhosis
- C. Psoriasis
- D. Lupus
Correct Answer: D
Rationale: The correct answer is D: Lupus. Lupus can affect the kidneys, leading to renal impairment. Renal impairment can decrease the body's ability to excrete ammonia, resulting in elevated levels. Renal failure (choice A) can also lead to elevated ammonia levels, but lupus specifically contributes to renal issues. Cirrhosis (choice B) primarily affects the liver, not kidneys. Psoriasis (choice C) is a skin condition and does not directly impact ammonia levels.
What should the nurse monitor when caring for a client receiving anticoagulant therapy?
- A. Monitor platelet count
- B. Monitor INR levels
- C. Monitor bleeding
- D. Monitor renal function
Correct Answer: B
Rationale: The correct answer is B: Monitor INR levels. INR (International Normalized Ratio) is a crucial parameter to monitor for clients on anticoagulant therapy, as it measures the effectiveness of the medication in preventing blood clots. By monitoring INR levels, the nurse can ensure the client is within the therapeutic range to prevent both bleeding and clotting complications.
Choice A (Monitor platelet count) is incorrect because anticoagulant therapy does not directly affect platelet count, and monitoring platelets is more relevant for clients on antiplatelet therapy.
Choice C (Monitor bleeding) is partially correct, but focusing solely on monitoring bleeding may not provide a comprehensive assessment of the client's response to anticoagulant therapy.
Choice D (Monitor renal function) is incorrect as anticoagulant therapy primarily affects coagulation factors and not renal function. Renal function monitoring may be necessary for certain medications but is not a primary consideration for anticoagulant therapy.
Which of the following statements about the mental health examination is true?
- A. A patient's family is the best resource for information about the patient's coping skills.
- B. It is usually sufficient to gather mental health information during the health history interview.
- C. It takes an enormous amount of extra time to integrate the mental health examination into the health history interview.
- D. It is usually necessary to perform a complete mental health examination to get a good idea of the patient's level of functioning.
Correct Answer: B
Rationale: The correct answer is B because the mental health examination should be integrated into the health history interview. This allows for a comprehensive understanding of the patient's mental health status. Gathering mental health information during the health history interview is crucial as it provides insight into the patient's current mental state, past history, and potential risk factors. This integrated approach is efficient and effective in assessing the patient's mental health needs.
A is incorrect because while family input can be valuable, it is not always the best or only resource for information about coping skills.
C is incorrect as integrating the mental health examination into the health history interview should not necessarily take an enormous amount of extra time if done efficiently.
D is incorrect as a complete mental health examination may not always be necessary to assess the patient's level of functioning; integrating mental health information into the health history interview can often provide sufficient insight.
What should be done for a client who is post-op and develops a fever within the first 48 hours?
- A. Administer antipyretics
- B. Monitor for signs of infection
- C. Administer fluids
- D. Perform an abdominal assessment
Correct Answer: B
Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.