Nokea
A nurse should carefully monitor a client for the following side effect of MgSO4:
- A. Visual blurring
- B. Tachypnea
- C. Epigastric pain
- D. Respiratory depression
Correct Answer: D
Rationale: The nurse should provide good distractors because these symptoms indicate that PIH has become more severe and may precede the convulsive or eclamptic phase. This is the opposite side effect of this medication. This is a common side effect of this medication and needs to be monitored and recorded frequently.
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The nurse is caring for a client who has diabetes insipidus. The nurse would describe this client's urine output pattern as:
- A. Anuria
- B. Oliguria
- C. Dysuria
- D. Polyuria
Correct Answer: D
Rationale: Polyuria is a primary symptom of diabetes insipidus. These clients have decreased or absent vasopressin secretion, which causes water loss in the urine and sodium increases.
A client receiving Parnate (tranylcypromine) is admitted in a hypertensive crisis. Which food is most likely to produce a hypertensive crisis when taken with the medication?
- A. Processed cheese
- B. Cottage cheese
- C. Cream cheese
- D. Cheddar cheese
Correct Answer: D
Rationale: MAOIs like tranylcypromine interact with tyramine-rich foods like aged cheddar cheese, causing hypertensive crisis. Processed, cottage, and cream cheeses have lower tyramine content.
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?
- A. I've been having a dull pain at the upper left shoulder.'
- B. My legs have been numb for three months.'
- C. I've only been urinating three times a day lately.'
- D. I don't remember anything in particular, I just haven't felt well.'
Correct Answer: D
Rationale: (A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
A client with a history of alcoholism is admitted with a diagnosis of cirrhosis. The nurse can expect the client to exhibit:
- A. Lower extremity edema
- B. Dilated pupils
- C. Warm, dry skin
- D. Bradycardia
Correct Answer: A
Rationale: Cirrhosis impairs liver function, leading to portal hypertension and hypoalbuminemia, causing lower extremity edema. Dilated pupils, warm skin, and bradycardia are not typical.
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?
- A. Position on side or abdomen.
- B. Maintain elbow restraints in place unless she is being directly supervised.
- C. Clean suture line every shift.
- D. Offer pacifier when she cries.
Correct Answer: B
Rationale: Placing the infant on her abdomen may allow for injury to the suture line. Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. The suture line is cleaned as often as every hour to prevent crusting and scarring. Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring.