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A nurse is teaching a client who has a new prescription for Sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?
- A. Chew tablet well before swallowing
- B. If you experience chest pain, call your physician immediately
- C. Take daily to prevent headaches
- D. Repeat dose in 1 hour for unrelieved headache
Correct Answer: B
Rationale: The correct answer is B: If you experience chest pain, call your physician immediately. This is crucial because Sumatriptan can sometimes cause chest pain or tightness as a side effect, which could indicate a serious issue like a heart problem. Instructing the client to contact their physician immediately ensures prompt medical attention if such symptoms occur, potentially preventing a serious complication. Choices A, C, and D are incorrect. A: Chewing Sumatriptan tablets is not recommended as it may alter the drug's absorption rate. C: Sumatriptan is not meant to be taken daily for headache prevention; it is used for acute migraine attacks. D: Repeating the dose in 1 hour is not advised as it can increase the risk of side effects and medication overuse headaches.
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A nurse is caring for a client who was injured by a blast of high-order explosives. Medics report secondary injuries from the explosion. The nurse anticipates what type of injuries?
- A. Blunt force trauma
- B. Hollow organ damage
- C. Post-trauma stress disorder
- D. Penetrating injuries
Correct Answer: D
Rationale: The correct answer is D: Penetrating injuries. High-order explosives cause secondary injuries like shrapnel or debris penetrating the body leading to penetrating injuries. Blunt force trauma (A) results from direct impact, not explosions. Hollow organ damage (B) is more likely with crush injuries. Post-trauma stress disorder (C) is a psychological response, not a physical injury. Therefore, the nurse should anticipate penetrating injuries as a result of the blast.
A nurse is caring for a client who questions the need for cardiac rehabilitation, stating, 'My heart is permanently damaged from the heart attack, so what's the point of cardiac rehabilitation?' Which response should the nurse prioritize?
- A. It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it
- B. Diet and exercise are good for you and good for your heart
- C. Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely
- D. Your doctor is the expert here, and I'm sure they would only recommend what is best for you
Correct Answer: C
Rationale: The correct answer is C: Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely. This response prioritizes providing the client with accurate information and managing expectations. It acknowledges the client's concern about the permanent damage to the heart but also emphasizes the benefits of cardiac rehabilitation in improving overall function and quality of life. It is essential for the nurse to address the client's misconceptions and provide education on the purpose and benefits of cardiac rehabilitation.
Choice A is incorrect as it focuses more on the client's emotional response rather than providing factual information. Choice B is too general and does not directly address the client's specific concerns. Choice D shifts the responsibility to the doctor without addressing the client's question directly.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room
- B. A private room
- C. A semi-private room with a client who has pediculosis capitis
- D. A positive-pressure isolation room
Correct Answer: B
Rationale: The correct answer is B: A private room. This is because scabies is transmitted through close skin-to-skin contact, so placing the client in a private room will help prevent the spread of the infestation to others. A negative-pressure isolation room (choice A) is used for airborne infections, not for scabies. Placing the client in a semi-private room with a client who has pediculosis capitis (lice) (choice C) increases the risk of cross-infection. Positive-pressure isolation rooms (choice D) are used to protect immunocompromised clients from airborne pathogens.
A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?
- A. Administer thrombolytics
- B. Call for help
- C. Provide the client with water to test the gag reflex
- D. Perform carotid massage
Correct Answer: B
Rationale: The correct action is to call for help (Choice B). This is because the client is displaying signs of a possible stroke, such as right-sided weakness and slurred speech. Time is critical in stroke management, and calling for help immediately can ensure the client receives prompt medical attention, such as a CT scan to confirm the diagnosis and appropriate treatment. Administering thrombolytics (Choice A) should only be done after a confirmed diagnosis to avoid potential harm. Providing water to test the gag reflex (Choice C) and performing carotid massage (Choice D) are not appropriate actions for a suspected stroke and could delay necessary interventions.
A nurse is providing care to a client with Myasthenia gravis who has lost 6 kg of weight over the past 2 months. What should the nurse suggest to improve this client's nutritional status?
- A. Restrict drinking fluids before and during meals
- B. Plan medication doses to occur before meals
- C. Increase the amount of fat and carbohydrates in meals
- D. Eat three large meals per day
Correct Answer: B
Rationale: The correct answer is B: Plan medication doses to occur before meals. This is because Myasthenia gravis can cause difficulty swallowing, leading to weight loss. Taking medication before meals can enhance the client's ability to eat by improving muscle strength for swallowing and chewing. Restricting fluids (A) may exacerbate swallowing difficulties. Increasing fat and carbohydrates (C) can lead to weight gain but may not address the swallowing issue. Eating three large meals (D) may be challenging for someone with swallowing difficulties.