Nokea
A worried mother confides in the nurse that she wants to change physicians because her infant is not getting better. The best response by the nurse is which of the following?
- A. This doctor has been on our staff for 20 years.'
- B. I know you are worried, but the doctor has an excellent reputation.'
- C. You always have an option to change. Tell me about your concerns.'
- D. I take my own children to this doctor.'
Correct Answer: C
Rationale: Acknowledging the mother's concerns and offering to discuss them respects her autonomy and opens a dialogue to address specific issues, potentially resolving misunderstandings or facilitating a change if needed.
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A client with a history of depression is prescribed fluoxetine (Prozac). The nurse should instruct the client to report which of the following side effects?
- A. Insomnia.
- B. Bradycardia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Fluoxetine commonly causes insomnia, which should be reported to manage treatment.
A client is receiving a blood transfusion when he begins to complain of difficulty breathing. The nurse notes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to manage which of the following complications?
- A. Anaphylactic reaction.
- B. Circulatory overload.
- C. Sepsis.
- D. Acute hemolytic reaction.
Correct Answer: B
Rationale: Difficulty breathing, elevated blood pressure, and cough suggest circulatory overload, a transfusion complication due to fluid volume excess.
A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next?
- A. Give 600 mg of acetaminophen (Tylenol) rectally, as ordered.
- B. Inspect the child's throat for redness and swelling.
- C. Have an appropriate-sized tracheostomy tube readily available.
- D. Obtain a specimen for a throat culture.
Correct Answer: C
Rationale: The symptoms suggest epiglottitis, a life-threatening condition requiring immediate airway management. Preparing a tracheostomy tube is the priority to ensure airway patency if obstruction occurs.
When preparing a 3-year-old child for blood specimens to be drawn for laboratory testing, the nurse should?
- A. Explain the procedure in advance
- B. Explain why the blood needs to be drawn
- C. Use distraction techniques during the procedure
- D. Provide verbal explanations about what will occur
Correct Answer: C
Rationale: Distraction techniques are most effective for a 3-year-old during painful procedures like blood draws, as they have limited understanding of explanations. Simple preparation may help, but distraction is key.
Which sign/symptom indicates that a client being treated with haloperidol may be experiencing an adverse effect of this medication?
- A. Nausea
- B. Hypotension
- C. Blurred vision
- D. Excessive drooling
Correct Answer: D
Rationale: Adverse effects of antipsychotic medications such as haloperidol include marked drowsiness and lethargy; extrapyramidal symptoms, including parkinsonism effects (drooling); dystonias; akathisia; and tardive dyskinesia. The correct option is a parkinsonism effect of this medication, excessive drooling. Nausea, hypotension, and blurred vision are occasional side effects of the medication.