Nokea
A patient with depression is prescribed fluoxetine. What is an important side effect for the nurse to monitor?
- A. Weight gain
- B. Bradycardia
- C. Dry mouth
- D. Suicidal thoughts
Correct Answer: D
Rationale: The correct answer is D: Suicidal thoughts. When a patient with depression is prescribed fluoxetine, there is a risk of increased suicidal thoughts, especially in the initial weeks of treatment. This is important for the nurse to monitor because it can lead to serious consequences. Weight gain (A) is a common side effect of fluoxetine but not as critical to monitor as suicidal thoughts. Bradycardia (B) and dry mouth (C) are not common side effects of fluoxetine and are less relevant to monitor in this scenario. Monitoring for suicidal thoughts is crucial for patient safety.
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What should be monitored to evaluate the effectiveness of enoxaparin in a patient with deep vein thrombosis (DVT)?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: C
Rationale: Rationale:
1. Enoxaparin is a low molecular weight heparin that primarily affects the intrinsic pathway of coagulation.
2. INR is used to monitor the effectiveness of anticoagulants affecting the intrinsic pathway.
3. Monitoring INR helps ensure the patient is within the therapeutic range to prevent clotting without excessive bleeding.
4. PT and PTT primarily evaluate the extrinsic and intrinsic pathways, respectively, not specific to enoxaparin.
5. Platelet count is not directly related to monitoring the effectiveness of enoxaparin in treating DVT.
While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding?
- A. Palpate for the presence of femoral pulses bilaterally.
- B. Assess for the presence of a positive Homan's sign.
- C. Observe the appearance of the skin on the client's legs.
- D. Watch the client's posture and balance during ambulation.
Correct Answer: C
Rationale: The correct answer is C: Observe the appearance of the skin on the client's legs. In clients with diabetes mellitus, poor circulation can lead to decreased hair growth on the legs. By observing the skin appearance, the nurse can look for signs of poor circulation such as dry skin, thinning of the skin, or discoloration. This assessment provides further data to support the finding of absent hair growth.
Choices A, B, and D are incorrect because they do not directly relate to the assessment of absent hair growth in clients with diabetes mellitus. Palpating for femoral pulses assesses circulation but does not specifically address the absence of hair growth. Assessing for Homan's sign evaluates for deep vein thrombosis, which is not directly related to hair growth. Watching posture and balance during ambulation assesses mobility and stability but does not provide information on hair growth or circulation in the legs.
A patient with chronic obstructive pulmonary disease (COPD) is prescribed ipratropium. What is the primary action of this medication?
- A. Reduce inflammation
- B. Relieve bronchospasm
- C. Suppress cough
- D. Thin respiratory secretions
Correct Answer: B
Rationale: The correct answer is B: Relieve bronchospasm. Ipratropium is an anticholinergic bronchodilator that works by relaxing the muscles in the airways, leading to bronchodilation and improved airflow. This helps to relieve bronchospasm, a common symptom in COPD. Choice A is incorrect because ipratropium does not have significant anti-inflammatory effects. Choice C is incorrect as ipratropium does not directly suppress cough. Choice D is incorrect as ipratropium does not specifically target respiratory secretions.
A patient with rheumatoid arthritis is taking prednisone. What is an important side effect for the nurse to monitor?
- A. Hyperglycemia
- B. Bradycardia
- C. Hypotension
- D. Hyperkalemia
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. Prednisone is a corticosteroid that can cause an increase in blood glucose levels by promoting gluconeogenesis and decreasing insulin sensitivity. Monitoring for hyperglycemia is crucial as it can lead to serious complications such as diabetic ketoacidosis. Bradycardia (B) and hypotension (C) are not typical side effects of prednisone, as it tends to cause fluid retention and hypertension. Hyperkalemia (D) is also unlikely as prednisone can actually cause hypokalemia due to increased renal potassium excretion.
A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response?
- A. You are lucky to be alive. Be grateful no one was killed.'
- B. I understand your car was not seriously damaged.'
- C. You are upset that this incident has brought you here.'
- D. Have you ever been in the emergency department before?'
Correct Answer: C
Rationale: The correct answer is C: "You are upset that this incident has brought you here." This response acknowledges the client's feelings of anger and validates her emotions, showing empathy and understanding. It demonstrates active listening and therapeutic communication, which is crucial in building trust and rapport with the client.
Choice A is incorrect as it dismisses the client's feelings of anger and invalidates her emotions by shifting the focus to being grateful instead. Choice B is incorrect as it minimizes the client's emotional response by focusing on the material aspect of the situation rather than addressing her feelings. Choice D is incorrect as it does not address the client's emotional state and is a closed-ended question that does not encourage further discussion or exploration of the client's feelings.