Nokea
During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate?
- A. Tinnitus and nausea
- B. Dermatitis and blurred vision
- C. Unconsciousness and acetone odor of the breath
- D. Chills and an elevation of temperature
Correct Answer: A
Rationale: These are toxic symptoms of sodium salicylate. (B, C, D) These are not symptoms associated with sodium salicylate.
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A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?
- A. A normal blood sugar level
- B. A decreased blood sugar level
- C. An increased blood sugar level
- D. Fluctuating levels with a predawn increase
Correct Answer: C
Rationale: Hyperglycemia occurs due to glucose production in response to the stress and illness of cellulitis.
The nurse is caring for a client with a diagnosis of abruptio placenta. Which intervention is most appropriate?
- A. Monitor fetal heart tones
- B. Administer tocolytics
- C. Place the client in Trendelenburg position
- D. Administer antibiotics
Correct Answer: A
Rationale: Abruptio placenta can cause fetal hypoxia making fetal heart tone monitoring critical to assess fetal well-being. Tocolytics are contraindicated Trendelenburg may worsen bleeding and antibiotics are not indicated unless infection is present.
Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?
- A. Phenothiazines
- B. Anticholinergics
- C. Anti-Parkinsonian drugs
- D. Tricyclic agents
Correct Answer: B
Rationale: This answer is incorrect. Phenothiazines are antipsychotic drugs and produce the symptoms. This answer is correct. Anticholinergic agents are often used prophylactically for extrapyramidal symptoms. They balance cholinergic activity in the basal ganglia of the brain. This answer is incorrect. Anti-Parkinsonian drugs would increase the symptoms. This answer is incorrect. Tricyclic agents are used for symptoms of depression.
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being 'on the move,' sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?
- A. Short, polite responses to interview questions
- B. Introspection related to his present situation
- C. Exaggerated self-importance
- D. Feelings of helplessness and hopelessness
Correct Answer: C
Rationale: During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. Grandiosity and an inflated sense of self-worth are characteristic of this disorder. Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.
The nurse is caring for a client with a history of asthma who is receiving Albuterol (Proventil). The nurse should monitor the client for:
- A. Tachycardia
- B. Hypotension
- C. Hypokalemia
- D. Hyperglycemia
Correct Answer: A
Rationale: Albuterol, a beta-agonist, commonly causes tachycardia as a side effect due to sympathetic stimulation. Hypotension, hypokalemia, and hyperglycemia are less frequent.