Nokea
A teenage client is admitted to the hospital because of an acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
- A. lungs
- B. liver
- C. kidneys
- D. adrenal glands
Correct Answer: B
Rationale: Acetaminophen is extensively metabolized in the liver. An acetaminophen overdose can lead to severe liver damage and even liver failure, which can be life-threatening. Choices A, C, and D are incorrect. Acetaminophen overdose does not typically cause life-threatening problems in the lungs, kidneys, or adrenal glands. While prolonged acetaminophen use may increase the risk of renal dysfunction, a single overdose primarily affects the liver.
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Tricyclics (Antidepressants) can sometimes have which of the following adverse effects on patients diagnosed with depression?
- A. Shortness of breath
- B. Fainting
- C. Large intestine ulcers
- D. Distal muscular weakness
Correct Answer: B
Rationale: The correct answer is 'Fainting.' Tricyclic antidepressants can cause fainting and hypotension as adverse effects. Shortness of breath (Choice A) is not a common side effect of tricyclics. Large intestine ulcers (Choice C) are not typically associated with tricyclic antidepressants. Distal muscular weakness (Choice D) is not a common adverse effect of tricyclics but is commonly associated with other medications.
What are the three major sequential maturational crises for females?
- A. puberty, pregnancy, and menopause.
- B. death of a spouse, menopause, and childbirth.
- C. rape, divorce, and menarche.
- D. dating, engagement, and separation.
Correct Answer: A
Rationale: The three major sequential maturational crises affecting females are puberty, pregnancy, and menopause. Puberty signifies the beginning of menarche, the first menstrual period. Pregnancy is a transformative experience with long-lasting effects on a woman's life. Menopause marks the end of menstrual cycles. These milestones are well-documented in research and are significant events in a woman's life. Nurses play a vital role in supporting females through these stages. Choices B, C, and D are incorrect as they do not accurately represent the recognized sequential maturational crises in a female's life.
A client tells the nurse that his wife's nagging really gets on his nerves. He asks the nurse to talk with her about her nagging during their family session tomorrow afternoon. Which of the following responses is the most therapeutic for the client?
- A. "Tell me more specifically about her complaints."?
- B. "Can you think of reasons why she might nag you so much?"?
- C. "I'll help you think about how to bring this up yourself tomorrow afternoon."?
- D. "Why do you want me to initiate this in tomorrow's session rather than you?"?
Correct Answer: C
Rationale: The most therapeutic response is to empower the client to address the issue himself. By offering assistance in thinking about how to bring up the topic during the family session, the nurse is promoting the client's autonomy and communication skills. This response encourages the client to take an active role in resolving the situation. Choices A and B focus on the wife's behavior, which is not the immediate concern during this interaction. Choice D challenges the client's request and shifts the responsibility back to the client, potentially hindering progress and discouraging open communication.
Which of the following isoenzymes is elevated in a client who has had a myocardial infarction?
- A. CPK-BB
- B. CPK-MM
- C. CPK-MB
- D. CPK-MI
Correct Answer: C
Rationale: CPK-MB is elevated in clients who have had a myocardial infarction. CPK-BB is elevated in clients who have brain damage, and CPK-MM is elevated in clients who have skeletal muscle damage. CPK-MI does not exist.
Which is the proper hand position for performing chest percussion?
- A. cup the hands
- B. use the side of the hands
- C. flatten the hands
- D. spread the fingers of both hands
Correct Answer: A
Rationale: The hands are cupped for performing percussion, producing a vibration that helps loosen respiratory secretions. The other hand positions do not accomplish this task.