Nokea
The nurse is providing teaching about lithium to the client and client's adult child. Select the 3 statements the nurse should include.
- A. Blurred vision is an expected adverse effect pf this medication
- B. It will take at least a week before this medication reaches a therapeutic level.
- C. This medication can cause nausea and drowsiness.
- D. You will be placed on a low sodium diet while taking this medication.
- E. This medication can cause weight gain.
Correct Answer: B,C,E
Rationale: Blurred vision is not typical; lithium takes time to reach therapeutic levels, causes nausea/drowsiness, and often leads to weight gain. A low-sodium diet is contraindicated due to risk of toxicity.
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Which of the following findings should the nurse report to the provider?
- A. Abdominal pain
- B. Belching
- C. Fatulence
- D. Sore throat
Correct Answer: A
Rationale: The correct answer is A: Abdominal pain. Abdominal pain is a significant finding that could indicate underlying health issues and requires immediate attention from the provider for further assessment and intervention. Belching and flatulence are common gastrointestinal symptoms that may not necessarily warrant immediate reporting. Sore throat, unless severe or persistent, can often be managed with over-the-counter remedies. It is important to prioritize reporting symptoms that could be indicative of serious conditions to ensure timely and appropriate care.
The client is at greatest risk for developing -----and-------
- A. Placental abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical Insufficiency
- E. Seizures
Correct Answer: A,E
Rationale: The correct answer is A (Placental abruption) and E (Seizures) because they are common complications during pregnancy. Placental abruption poses a risk of severe bleeding and fetal distress, leading to adverse outcomes. Seizures, specifically eclampsia, can occur due to uncontrolled hypertension in pregnancy, putting both the mother and baby at risk. Hypoglycemia (B), heart failure (C), and cervical insufficiency (D) are potential complications but are not the greatest risks compared to placental abruption and seizures in this context.
A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Offer small amounts of clear liquids 6 hr following surgery
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr
- D. Apply a warm compress to the operative site every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial for the comfort and well-being of the child. Scheduled analgesics help maintain a consistent level of pain relief, preventing peaks and valleys in pain intensity. This approach is especially important in the initial 24 hours following surgery when pain is typically more intense. Offering small amounts of clear liquids 6 hours post-surgery (Choice A) may not be appropriate as the child may still be recovering from anesthesia and at risk of nausea or vomiting. Giving cromolyn nebulized solution every 8 hours (Choice C) is not indicated for postoperative pain management. Applying a warm compress to the operative site every 4 hours (Choice D) may provide some comfort but does not address the underlying need for analgesia.
Which of the following actions should the nurse include in the plan of care?
- A. Encourage physical activity prior to bedtime
- B. Replace the carpet with hardwood floors
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the top of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the top of exterior doors. This action is crucial in ensuring the safety and security of the individual, especially in cases where the person may be at risk of wandering or elopement. Placing locks at the top of exterior doors can prevent the individual from leaving the house unsupervised, which is essential for their safety. Encouraging physical activity prior to bedtime (A) may disrupt sleep patterns. Replacing carpet with hardwood floors (B) is not directly related to the safety of the individual. Wearing clothing with zippers instead of buttons (C) may be a personal preference but does not address safety concerns.
Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. kidney function tests
- C. hemoglobin and hematocrit
- D. serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Monitoring liver function is crucial as it assesses the health of the liver, detecting any abnormalities or diseases. Liver function tests include assessing levels of enzymes, proteins, and bilirubin. Abnormal results can indicate liver damage or dysfunction. Monitoring kidney function (B) is important but not the priority in this scenario. Hemoglobin and hematocrit (C) are essential for assessing blood health but not specific to liver function. Serum sodium and potassium (D) are more related to electrolyte balance than liver function.