After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myelinolysis. Which intervention should the nurse implement first?
- A. Reorient client to his room
- B. Place a patch on one eye
- C. Evaluate client's ability to swallow
- D. Perform range of motion exercises
Correct Answer: A
Rationale: Reorienting the client helps in managing confusion and disorientation, which are common in pontine myelinolysis.
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The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide?
- A. Invite friends over regularly to share in meal times
- B. Encourage the client to drink clear liquids between meals
- C. Coach the client to make an intentional effort to swallow
- D. Talk to the healthcare provider about prescribing an appetite stimulant
Correct Answer: A
Rationale: Social interaction during meals can improve appetite and intake in clients with Parkinson's disease.
Regarding sumatriptan:
- A. It has a good oral bioavailability
- B. Its onset of action is within 15 minutes of subcutaneous administration
- C. Is a 5-HT agonist
- D. Acts on adrenergic and muscarinic receptors
Correct Answer: B
Rationale: Its onset of action is within 15 minutes of subcutaneous administration
What are FIVE possible etiologies for a heart rate of 40 bpm with atrial rate of 92 bpm and AV-dissociation in a 4-year-old girl?
- A. Congenital CHB from maternal Lupus
- B. Fetal myocarditis
- C. CCTGA
- D. Medication induced
Correct Answer: A
Rationale: Congenital heart block from maternal conditions like lupus can present with low heart rate and AV dissociation in a young child.
What is the priority nursing action for a child who is post-operative following a tonsillectomy?
- A. Provide pain management.
- B. Encourage fluid intake.
- C. Monitor for signs of bleeding.
- D. Educate the child about proper oral hygiene.
Correct Answer: C
Rationale: The priority after a tonsillectomy is to monitor for bleeding, as this can be a serious complication.
Right to left shunts include:
- A. Fallot's tetralogy
- B. Tricuspid atresia
- C. Eisenmenger complex
- D. Ductus arteriosus in the fetus
Correct Answer: A
Rationale: Fallot's tetralogy is a congenital heart defect that includes a right-to-left shunt, allowing deoxygenated blood to bypass the lungs.
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