Nokea
After 4 electroconvulsive treatments over 2 weeks, a client is very upset and states 'I am so confused. I lose my money. I just can't remember telephone numbers.' The most therapeutic response for the nurse to make is
- A. You were seriously ill and needed the treatments.'
- B. Don't get upset. The confusion will clear up in a day or two.'
- C. It is to be expected since most clients have the same results.'
- D. I can hear your concern and that your confusion is upsetting to you.'
Correct Answer: D
Rationale: Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short-term effects would be discussed.
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A nurse is working in an outpatient orthopedic clinic. During the patient's history the patient reports, 'I tore 3 of my 4 Rotator cuff muscles in the past.' Which of the following muscles cannot be considered as possibly being torn?
- A. Teres minor
- B. Teres major
- C. Supraspinatus
- D. Infraspinatus
Correct Answer: B
Rationale: Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis make up the Rotator Cuff.
The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following instructions should the nurse include?
- A. Take the medication daily to prevent migraines.
- B. Report any chest pain.
- C. Stop the medication if headaches decrease.
- D. Avoid regular neurological exams.
Correct Answer: B
Rationale: Chest pain may indicate vasoconstriction, a serious sumatriptan side effect. Options A, C, and D are incorrect.
The nurse is preparing a five-year-old child for surgery.
- A. What is the best action for the nurse when the informed consent for a five-year-old’s surgery is signed by the mother, and the parents are divorced with joint legal custody?
- B. Notify the physician.
- C. Inform surgery.
- D. Contact the father to obtain consent.
- E. Continue the child’s preoperative preparation.
Correct Answer: D
Rationale: In cases of joint legal custody, consent from either parent is sufficient for surgical procedures. Since the mother has signed the informed consent, no further action is needed, and the nurse should continue preoperative preparation. Notifying the physician, informing surgery, or contacting the father is unnecessary.
A 70-year-old man with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question?
- A. Propranolol (Inderal), 80 mg PO QID.
- B. Verapamil (Nifedipine), 40 mg PO TID.
- C. Tetrahydrozoline (Visine), 2 gtts OU TID.
- D. Timolol (Timoptic solution), 1 gtt OU QD.
Correct Answer: C
Rationale: contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension
The nurse is caring for a client with a history of bipolar disorder who is receiving valproic acid (Depakote) 500 mg PO bid. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Liver enzymes elevated to twice normal.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: Elevated liver enzymes suggest hepatotoxicity, a serious side effect of valproic acid, requiring immediate evaluation to prevent liver failure. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.