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An adult who has osteoarthritis tells the clinic nurse that her joints have been more painful lately and her head aches and her ears are 'making funny buzzing sounds.' What question should the nurse ask the client?
- A. How long have you had arthritis?
- B. Have you recently been exposed to loud noises?
- C. What do you think is causing your joints to hurt more lately?
- D. What medication have you been taking for your painful joints?
Correct Answer: D
Rationale: New symptoms with increased joint pain suggest possible medication side effects (e.g., NSAIDs causing tinnitus), making medication history critical.
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A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain and is scheduled for paracentesis. Which of the following nursing actions should be implemented prior to the procedure? Select all that apply.
- A. Ensure that informed consent has been obtained
- B. Place the client in reverse Trendelenburg position
- C. Place the client on NPO status
- D. Request the client empty their bladder
- E. Take baseline vital signs and weight
Correct Answer: A,D,E
Rationale: Informed consent ensures understanding, emptying the bladder prevents injury during needle insertion, and baseline vital signs/weight monitor fluid shifts. Reverse Trendelenburg is inappropriate; upright positioning is typical. NPO status isn't required for paracentesis.
A client with schizophrenia is ready to begin participating in therapeutic activities. The nurse should suggest that the client:
- A. Participate on the unit softball team
- B. Attend a class on psychotropic medication
- C. Participate in art activities with three other clients
- D. Watch TV in the unit day room
Correct Answer: C
Rationale: Art activities with a small group provide a structured, low-stress environment suitable for a client with schizophrenia, promoting social interaction without overwhelming them.
Which findings reflect vital signs that are concerning and require further nursing monitoring and intervention? Select all that apply.
- A. After albuterol administration, 5-year-old client has a pulse of 120/min and reports tremor
- B. After hydromorphone 1 mg IV push, blood pressure decreases from 130/80 mm Hg to 110/70 mm Hg
- C. Blood pressure is 90/60 mm Hg, and the nurse is preparing to administer prescribed nifedipine
- D. Blood pressure was 120/80 mm Hg and pulse was 80/min before blood transfusion, current values are 90/70 mm Hg and 100/min, respectively
- E. Fetal heart rate monitored during labor decreases from 140/min to 100/min following a contraction
Correct Answer: C,D,E
Rationale: Hypotension (90/60 mm Hg) with nifedipine risks severe hypotension. Transfusion-related hypotension and tachycardia suggest a reaction. Fetal heart rate deceleration post-contraction indicates potential distress. Albuterol's tachycardia/tremor and hydromorphone's mild BP drop are expected.
An adult client who is ambulating in the corridor with the nurse becomes dizzy and faint. What should the nurse do at this time?
- A. Have her put her head between her legs
- B. Quickly go to get help
- C. Guide her to a chair in the corridor and ease her into it
- D. Encourage the client to walk faster
Correct Answer: C
Rationale: Guiding the client to a chair prevents falls and ensures safety during dizziness. Head positioning, seeking help, or faster walking are unsafe or impractical.
The nurse is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching?
- A. I can restart my paroxetine once I get back home.
- B. I can take acetaminophen for headaches.
- C. I will avoid foods and drinks that contain tyramine.
- D. I will report any increased fever or diarrhea.
Correct Answer: A
Rationale: Linezolid interacts with SSRIs like paroxetine, risking serotonin syndrome, requiring a washout period. Acetaminophen is safe, tyramine avoidance prevents hypertensive crises, and reporting fever/diarrhea monitors treatment response.