Nokea
Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?
- A. Hold the lithium and obtain a stat lithium level to determine therapeutic effectiveness.
- B. Continue the lithium and immediately notify the physician about the assessment findings.
- C. Continue the lithium and reassure the client that these temporary side effects will subside.
- D. Hold the lithium and monitor the client for signs and symptoms of increasing toxicity.
Correct Answer: C
Rationale: These symptoms are common side effects of lithium, especially early in treatment, and typically subside as the body adjusts. Continuing the medication and reassuring the client is appropriate unless symptoms worsen.
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The nurse is caring for a client with a history of Crohn's disease who is prescribed mesalamine (Asacol). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild diarrhea.
- B. Abdominal pain.
- C. Fever.
- D. Headache.
Correct Answer: C
Rationale: Fever may indicate an exacerbation of Crohn's disease or a side effect of mesalamine, requiring immediate reporting.
A client diagnosed with valvular heart disease is at risk for developing heart failure. What should the nurse assess as the priority when monitoring for heart failure?
- A. Heart rate
- B. Breath sounds
- C. Blood pressure
- D. Activity tolerance
Correct Answer: B
Rationale: Breath sounds are the best way to assess for the onset of heart failure. The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure.
A client who is brought to the emergency department has experienced a burn covering greater than 25% of his total body surface area (TBSA). When reviewing the laboratory results drawn on the client, which value should the nurse most likely expect to note?
- A. Hematocrit 65% (0.65)
- B. Albumin 4.0 g/dL (40 g/L)
- C. Sodium 140 mEq/L (140 mmol/L)
- D. White blood cell (WBC) count 6000 mm^3 (6 x 10^9/L)
Correct Answer: A
Rationale: Extensive burns covering greater than 25% of the TBSA result in generalized body edema in both burned and nonburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels elevate in the first 24 hours after injury (the emergent phase) as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit is 42 to 52% (0.42-0.52) in the male and 37 to 47% (0.37-0.47) in the female. The normal albumin is 3.5-5 g/dL (35-50 g/L). The normal sodium level is 135 to 145 mEq/L (135-145 mmol/L). The normal WBC count is 5000 to 10,000 mm^3 (5-10 x 10^9/L).
A client has been given a prescription for propantheline as adjunctive treatment for peptic ulcer disease. How should the nurse tell the client to take this medication?
- A. With meals
- B. With antacids
- C. Just after meals
- D. Thirty minutes before meals
Correct Answer: D
Rationale: Propantheline is an antimuscarinic anticholinergic medication that decreases gastrointestinal secretions. It should be administered 30 minutes before meals to reduce acid secretion before food intake stimulates gastric acid production. Administering with meals or just after meals would reduce its effectiveness, and taking it with antacids could interfere with its absorption.
Which basic activity of daily living assistive device can be useful for the client who is affected with poor fine motor coordination?
- A. An aphasia aid
- B. A button hook
- C. Honey thickened liquids
- D. A word board
Correct Answer: B
Rationale: A button hook assists clients with poor fine motor coordination in fastening buttons, supporting independence in dressing.