Nokea
A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with over dosage?
- A. Memory loss and lack of appetite
- B. Confusion and fatigue
- C. Heightened reflexes
- D. Tinnitus and spasticity
Correct Answer: B
Rationale: Lidocaine Hydrochloride can cause fatigue and confusion if an over dosage occurs.
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A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the 'evil eye.' The nurse should communicate to other personnel that the appropriate approach is to
- A. Touch the baby after looking at him
- B. Talk very slowly while speaking to him
- C. Avoid touching the child
- D. Look only at the parents
Correct Answer: A
Rationale: In many cultures, an 'evil eye' is cast when looking at a person without touching him. Thus, the spell is broken by touching while looking or assessing.
While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions?
- A. Maintain good oral hygiene and dental care
- B. Omit medication if the child is seizure free
- C. Administer acetaminophen to promote sleep
- D. Serve a diet that is high in iron
Correct Answer: A
Rationale: Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized.
A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes. She sits for hours rocking back and forth and appears to be talking to someone at intervals. She does not eat or bathe or relate to others. How should the nurse approach this client upon admission?
- A. Explain the unit routines to her in detail
- B. Ask her if she has any question about the unit or what she is supposed to do
- C. Briefly explain the most essential information and then sit with her
- D. Take her by the hand and orient her to the unit
Correct Answer: C
Rationale: A withdrawn client may be overwhelmed by detailed explanations. Brief information and quiet presence build trust and reduce anxiety.
A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker 'force feed' the client. What is the priority nursing action?
- A. Explain to the family that this is a normal physiological response to dying
- B. Explore the family’s thoughts and concerns about the client’s refusal of food
- C. Recommend a feeding tube
- D. Tell the family that 'force feeding' the client could cause the client to choke on the food
Correct Answer: A
Rationale: Explaining that anorexia is normal in dying (A) addresses family distress and aligns with hospice goals. Exploring concerns (B) is secondary, feeding tubes (C) are inappropriate, and choking warnings (D) may escalate distress.
After a recent outbreak of varicella in an elementary school, the practical nurse is assisting with the development of an informative letter to parents. Which of the following instructions are appropriate to include? Select all that apply.
- A. Apply calamine lotion to soothe lesions
- B. Clip your child’s fingernails short
- C. Ensure that your child’s vaccinations are up to date
- D. Keep your child home until lesions have crusted
- E. Place mittens on your child’s hands when sleeping
Correct Answer: A,B,C,D,E
Rationale: Calamine lotion (A) relieves itching, short nails (B) and mittens (E) prevent scratching, vaccinations (C) protect against future infection, and isolation until crusted (D) prevents transmission. All are appropriate.