Nokea
A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement?
- A. Measure urine output hourly to assess for rental perfusion
- B. Request a prescription for pain medication
- C. Use an automated BP machine to monitor for hypotension
- D. Provide a quiet environment with low lighting
Correct Answer: C
Rationale: Monitoring blood pressure is crucial after administering an antihypertensive to ensure the client does not become hypotensive.
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The following conditions are associated with hyperammonaemia:
- A. Reye syndrome
- B. Citrullinaemia
- C. Methylmalonic acidaemia
- D. Homocystinuria
Correct Answer: A
Rationale: Reye syndrome is associated with hyperammonaemia due to liver dysfunction and impaired urea cycle function, leading to ammonia accumulation.
Which finding might delay a cardiac catheterization procedure on a 1-year-old?
- A. 30th percentile for weight
- B. Severe diaper rash
- C. Allergy to soy
- D. Oxygen saturation of 91% on room air
Correct Answer: B
Rationale: A severe diaper rash may indicate potential infection, which is a contraindication for the standard groin approach during catheterization.
The following drugs induce hepatic enzymes:
- A. Rifampicin
- B. Phenobarbitone
- C. Cimetidine
- D. Erythromycin
Correct Answer: A
Rationale: Rifampicin is known to induce hepatic enzymes, which can increase the metabolism of other drugs and reduce their efficacy.
A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action?
- A. Encourage frequent mouth care
- B. Cleanse the tongue and mouth with glycerin swabs
- C. Obtain a soft diet for the client
- D. Administer a topical analgesic per PRN protocol.
Correct Answer: D
Rationale: Administering a topical analgesic provides immediate pain relief, allowing the client to tolerate mouth care and other interventions.
Which of the following children are abnormal?
- A. 18-month-old who is able to put three blocks on top of each other and has a 2-word vocabulary
- B. 3-month-old who has just attained good head control, and is reaching for objects
- C. 5-year-old with difficulty in reading sentences from a book
- D. Bottom-shuffler who is still not walking at 16 months
Correct Answer: C
Rationale: A 5-year-old with difficulty reading sentences from a book may indicate a developmental or learning disorder, which is considered abnormal for that age.