Nokea
Before administering Theodur to a 10-year-old being treated for asthma, the nurse should check the:
- A. Urinary output
- B. Blood pressure
- C. Pulse
- D. Temperature
Correct Answer: C
Rationale: The correct answer is to check the pulse. Theodur is a bronchodilator used in asthma treatment, and one of the side effects is tachycardia (increased heart rate). Therefore, it is essential to assess the pulse rate before administering Theodur to monitor for any potential tachycardia. Checking urinary output (Choice A), blood pressure (Choice B), and temperature (Choice D) are not directly related to the immediate side effects of bronchodilators like Theodur in this context, making them unnecessary assessments.
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The nurse and a colleague are on the elevator after their shift, and they hear a group of health caregivers discussing a recent client scenario. Which client right might be breached?
- A. right to refuse treatment
- B. right to continuity of care
- C. right to confidentiality
- D. right to reasonable responses to requests
Correct Answer: C
Rationale: The right to confidentiality of client information might be breached when client care situations are discussed in public areas or without regard to maintaining the information as private and confidential. In this scenario, discussing a client scenario in a public elevator could potentially lead to the breach of the client's right to confidentiality. The other choices, such as the right to refuse treatment, right to continuity of care, and right to reasonable responses to requests, are not typically breached in this context. It is important to uphold client confidentiality to maintain trust and privacy in healthcare settings.
The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
- A. "Walk about a mile a day to prevent calcium loss."?
- B. "Increase the fiber in your diet."?
- C. "Report nausea to the doctor immediately."?
- D. "Drink at least eight large glasses of water a day."?
Correct Answer: D
Rationale: Cyclophosphamide (Cytoxan) can cause hemorrhagic cystitis, a condition characterized by inflammation of the bladder wall leading to bleeding. To prevent this complication, the client should drink at least eight glasses of water a day. Walking to prevent calcium loss (choice A) and increasing fiber intake (choice B) are not directly related to the side effects of Cytoxan, making them unnecessary instructions in this case. While nausea is a common side effect of chemotherapy, the immediate reporting of nausea to the doctor (choice C) is important but not specifically related to the use of Cytoxan in this scenario.
When a woman is having her first child, she is experiencing which type of crisis event?
- A. situational
- B. maturational
- C. adventitious
- D. reactive
Correct Answer: B
Rationale: A maturational crisis occurs when an individual reaches a new stage of development, such as becoming a parent for the first time, and needs to develop new coping strategies to adapt to this change. Situational crises (Choice A) arise from external sources, not developmental milestones. Adventitious crises (Choice C) are caused by external events like natural disasters and are not related to personal development stages. Reactive crises (Choice D) are responses to specific stressors and are not associated with developmental milestones like becoming a parent for the first time.
A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?
- A. She dresses herself
- B. She pulls a toy behind her
- C. She can build a tower of eight blocks
- D. She can copy a horizontal or vertical line
Correct Answer: B
Rationale: The correct answer is 'She pulls a toy behind her.' This behavior is consistent with the developmental stage of an 18-month-old who enjoys push-pull toys. Dressing oneself usually begins around 3 years old, building a tower of eight blocks at approximately 3 years old, and copying a horizontal or vertical line at about 4 years old. Choices A, C, and D are incorrect as they represent skills that are typically observed in older children.
While admitting a client to an acute-care psychiatric unit, the nurse asks about substance abuse based on:
- A. psychiatric disorders' higher prevalence in addicted populations
- B. individuals with psychiatric disorders' increased susceptibility to substance abuse
- C. the importance of detecting and diagnosing substance disorders in acute-care psychiatric settings
- D. the significant impact of undetected substance problems on the treatment of psychiatric disorders
Correct Answer: B
Rationale: The correct answer is 'individuals with psychiatric disorders' increased susceptibility to substance abuse.' It is crucial to inquire about substance abuse during admission to an acute-care psychiatric unit because individuals with psychiatric disorders are more prone to experiencing substance abuse issues. Addressing substance abuse is vital for effective treatment and to prevent relapse in psychiatric disorders. Option A is incorrect as it focuses on the prevalence of psychiatric illness in addicted populations rather than the relationship between psychiatric disorders and substance abuse. Option C is incorrect as it exaggerates the ease of detecting and diagnosing substance disorders in acute-care psychiatric settings. Option D is incorrect as undetected substance problems can indeed significantly impact the treatment of psychiatric disorders, but the main reason for inquiring about substance abuse is the increased susceptibility of individuals with psychiatric disorders to such issues.