Nokea
An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL (143 umol/L). Which clinical manifestation associated with theophylline toxicity should worry the nurse most?
- A. Alterations in color vision
- B. Gum (gingival) hypertrophy
- C. Hyperthermia
- D. Seizure activity
Correct Answer: D
Rationale: Theophylline has narrow therapeutic index and plasma concentrations >20 mcg/mL (111 umol/L) are associated with theophylline drug toxicity. Toxicity can be acute or chronic. Conditions associated with chronic toxicity include advanced age (>60), drug interactions (eg, alcohol, macrolide and quinolone antibiotics), and liver disease. Acute toxicity is associated with intentional or accidental overdose. Symptoms of toxicity usually manifest as central nervous system stimulation (eg, headache, insomnia, seizures), gastrointestinal disturbances (eg, nausea, vomiting), and cardiac toxicity (eg, arrhythmia).
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Social support systems include all of the following except:
- A. call-in help lines.
- B. emotional assistance provided by others.
- C. community support groups.
- D. use of coping skills and verbalization for anger management.
Correct Answer: D
Rationale: Coping skills and verbalization are personal strategies, not social support systems, which involve external resources like help lines, emotional assistance, or groups. Psychosocial Integrity
A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate?
- A. Correction with laser surgery
- B. Eye drops in the affected eye
- C. Measurement of intraocular pressure
- D. Patching of the unaffected eye
Correct Answer: D
Rationale: Patching the unaffected eye strengthens the weaker eye in strabismus by forcing its use, a common non-surgical treatment in children. Laser surgery is not typically used, eye drops are irrelevant, and intraocular pressure measurement is for glaucoma, not strabismus.
The nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations and has a new prescription for an oral antipsychotic. Which of the following actions should the nurse take?
- A. Provide music for the client
- B. Use gentle touch to calm the client
- C. Instruct the client to ignore the hallucinations
- D. Tell the client the medication will alleviate the hallucinations within a few hours
Correct Answer: C
Rationale: Instructing the client to ignore hallucinations helps them manage symptoms by redirecting focus, a practical coping strategy. Music or touch may exacerbate distress, and antipsychotics typically take days to weeks to reduce hallucinations, not hours.
Which client should the nurse call first?"
- A. Client with a left humerus fracture reporting stiffness and limited range of motion in the left shoulder
- B. Client with a left shoulder sling due to a fractured clavicle reporting vomiting after taking oxycodone
- C. Client with a right leg cast applied yesterday for a fractured ankle reporting itching in the right foot
- D. Client with fibromyalgia reporting unresolved burning pain and prescribed amitriptyline 1 week ago
Correct Answer: C
Rationale: Itching in a new cast may indicate skin irritation or an allergic reaction, requiring prompt assessment to prevent complications. Stiffness in a fracture or unresolved fibromyalgia pain are less urgent.
The nurse is caring for a client who had a laparoscopic cholecystectomy 3 days ago. The client's WBC count has increased over the past 2 days. Which assessment finding is most concerning?
- A. Client rating left shoulder pain as 4 on a scale of 0-10
- B. Greenish-gray drainage noted on surgical dressing
- C. Productive cough with thick, green sputum
- D. Stiff abdomen with rebound tenderness on palpation
- E. Warm, reddened area around the incision site
Correct Answer: D
Rationale: A stiff abdomen with rebound tenderness suggests peritonitis, a life-threatening complication post-cholecystectomy, requiring immediate intervention. Shoulder pain is common due to referred pain, drainage and incision redness suggest localized infection, and a cough may indicate a respiratory issue, but peritonitis is most urgent.