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During an acute asthma exacerbation, what is the priority nursing intervention for a client with asthma?
- A. Administer corticosteroids to reduce airway inflammation.
- B. Position the client in high-Fowler's position.
- C. Administer short-acting beta-agonists (SABAs) as prescribed.
- D. Obtain a peak flow reading to assess the severity of the exacerbation.
Correct Answer: C
Rationale: The priority nursing intervention during an acute asthma exacerbation is to administer short-acting beta-agonists (SABAs) as prescribed. SABAs help in quickly relieving bronchospasm and are considered the first-line treatment for acute exacerbations. Administering corticosteroids, positioning the client, and obtaining a peak flow reading are important interventions but come after administering SABAs in the management of acute asthma exacerbation.
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A 30-year-old male is being treated with testosterone enanthate for delayed puberty. What side effect should the nurse inform the patient about?
- A. Increased libido
- B. Decreased muscle mass
- C. Breast tenderness
- D. Increased aggression
Correct Answer: D
Rationale: The correct side effect that the nurse should inform the patient about when receiving testosterone enanthate therapy for delayed puberty is increased aggression. Testosterone therapy can lead to mood changes, including increased aggression in some individuals. Therefore, it is essential for healthcare providers to educate patients about this potential side effect. Choices A, B, and C are incorrect because testosterone therapy is more likely to increase libido, promote muscle mass growth, and may cause breast tenderness due to hormonal imbalances.
A client arrives with symptoms of stroke. What should the nurse assess first?
- A. Level of consciousness
- B. Blood pressure
- C. Pupil reaction
- D. Heart rate
Correct Answer: A
Rationale: Assessing the level of consciousness is a critical first step in evaluating a potential stroke. Changes in the level of consciousness can indicate the severity and location of brain damage, helping to guide immediate interventions. Assessing blood pressure, pupil reaction, and heart rate are also important aspects of the assessment in a suspected stroke patient. However, the priority is to quickly determine the client's level of consciousness to assess their neurological status.
A patient is prescribed estradiol (Estrace) for hormone replacement therapy. What should the nurse monitor during this therapy?
- A. Blood pressure
- B. Blood glucose levels
- C. Liver function tests
- D. Kidney function tests
Correct Answer: C
Rationale: During estradiol therapy, the nurse should monitor liver function tests. Estradiol can potentially impact liver function, making it essential to assess for any signs of liver dysfunction. Monitoring blood pressure (Choice A) is not directly related to estradiol therapy. While blood glucose levels (Choice B) should be monitored in patients taking certain medications like corticosteroids or antipsychotics, it is not typically necessary for patients on estradiol therapy. Kidney function tests (Choice D) are not the priority for monitoring during estradiol therapy, as the liver is more commonly affected.
A patient is starting on finasteride (Proscar) for the treatment of benign prostatic hyperplasia (BPH). What should the nurse include in the patient teaching?
- A. The medication will cure BPH after treatment is complete.
- B. The effects of the medication may take several weeks or months to become noticeable.
- C. The medication may cause increased hair growth.
- D. The medication may decrease libido.
Correct Answer: B
Rationale: The correct answer is B. The effects of finasteride in treating BPH may take several weeks or months to become noticeable. It is important for the nurse to educate the patient about this expected time frame to manage expectations. Choice A is incorrect because finasteride does not cure BPH but helps in managing symptoms. Choice C is incorrect as one of the side effects of finasteride is decreased hair growth. Choice D is incorrect as finasteride may cause a decrease in libido as a side effect.
The college health nurse is providing health education for freshmen. Which of the following pieces of information about immunizations is applicable to individuals of this age group?
- A. The oral polio vaccine should be updated.
- B. The yearly administration of flu vaccine is recommended.
- C. The tetanus toxoid should be within 2 years.
- D. The administration of hepatitis A vaccine is mandatory.
Correct Answer: B
Rationale: For freshmen in college, the yearly administration of the flu vaccine is recommended. This is important to protect against seasonal influenza outbreaks that can spread rapidly in close living quarters such as dormitories. Choice A is incorrect as oral polio vaccine is not typically given to individuals of this age group. Choice C is incorrect as tetanus toxoid boosters are usually recommended every 10 years, not within 2 years. Choice D is incorrect as the administration of the hepatitis A vaccine is not mandatory for all individuals in this age group.