Nokea
Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority?
- A. obtain a complete blood count
- B. obtain a health and dietary history
- C. refer to a provider for a physical examination
- D. measure height and weight
Correct Answer: B
Rationale: obtain a health and dietary history. Initially, the nurse should obtain information about the chronicity of and details about constipation, recent changes in bowel habits, physical and emotional health, medications, activity pattern, and food and fluid history. This information may suggest causes as well as an appropriate, safe treatment plan.
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A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be to
- A. cover the areas with dry sterile dressings
- B. assess for dyspnea or stridor
- C. initiate intravenous therapy
- D. administer pain medication
Correct Answer: B
Rationale: assess for dyspnea or stridor. Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.
A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?
- A. Change in libido, breast enlargement
- B. Sore throat, fever
- C. Abdominal pain, nausea, diarrhea
- D. Dyspnea, nasal congestion
Correct Answer: B
Rationale: A sore throat and fever may be findings of agranulocytosis, a serious side effect of chlorpromazine (Thorazine).
The nurse is caring for a client with clinical depression who is receiving a monoamine oxidase inhibitor (MAOI). When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?
- A. Avoid chocolate and cheese
- B. Take frequent naps
- C. Take the medication with milk
- D. Avoid walking without assistance
Correct Answer: A
Rationale: Avoid chocolate and cheese. Foods high in tryptophan, tyramine, and caffeine, such as chocolate, wine, and cheese may precipitate hypertensive crisis.
The HCP prescribes metronidazole 0.5 g orally three times daily for the client with an infection. The label states that each tablet is 250 mg. How many tablets should the nurse prepare to administer for one dose?
Correct Answer: 2
Rationale: 0.5 g = 500 mg; 500 mg/ 250 mg/tablet = 2 tablets per dose.
Which of these findings would the nurse more closely associate with anemia in a 10 month-old infant?
- A. hemoglobin level of 12 g/dL
- B. pale mucosa of the eyelids and lips
- C. hypoactivity
- D. a heart rate between 80 and 130
Correct Answer: B
Rationale: pale mucosa of the eyelids and lips. In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia.