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During the initial assessment of a client with a history of substance abuse admitted for detoxification, which intervention is most important?
- A. Obtain a detailed substance use history.
- B. Establish a trusting nurse-client relationship.
- C. Evaluate the client's physical health status.
- D. Determine the client's readiness for change.
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's physical health status. This is crucial during detoxification as substance withdrawal can lead to serious physical health complications such as seizures or cardiac issues. Assessing physical health status allows for prompt intervention if needed. Obtaining a detailed substance use history (A) can provide valuable information but is not immediate priority during initial assessment. Establishing a trusting nurse-client relationship (B) is important but ensuring physical safety comes first. Determining client's readiness for change (D) is important for long-term treatment planning but not as urgent as assessing physical health status.
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A client with heart failure is receiving digoxin (Lanoxin). Which finding indicates that the medication is effective?
- A. Increased heart rate.
- B. Decreased pedal edema.
- C. Elevated blood pressure.
- D. Improved urine output.
Correct Answer: B
Rationale: The correct answer is B: Decreased pedal edema. Digoxin is a medication commonly used to treat heart failure by improving the heart's ability to pump effectively. As the medication helps to reduce fluid buildup in the body, a decrease in pedal edema (swelling in the feet and ankles) indicates that digoxin is effectively managing the client's heart failure. Increased heart rate (A) may indicate digoxin toxicity, elevated blood pressure (C) is not a typical indicator of digoxin effectiveness, and improved urine output (D) may be a result of diuretic therapy rather than specifically digoxin efficacy in heart failure management.
A client with heart failure is prescribed digoxin (Lanoxin). Which sign of digoxin toxicity should the nurse teach the client to report?
- A. Increased appetite.
- B. Yellow or blurred vision.
- C. Weight gain.
- D. Nasal congestion.
Correct Answer: B
Rationale: The correct answer is B: Yellow or blurred vision. Digoxin toxicity can lead to visual disturbances, such as yellow or blurred vision, due to its effects on the optic nerve. The nurse should teach the client to report this symptom immediately as it indicates a serious adverse effect. Increased appetite (A), weight gain (C), and nasal congestion (D) are not specific signs of digoxin toxicity and are more commonly associated with other health conditions or side effects of medications. It is crucial for the nurse to emphasize the importance of monitoring and reporting any visual changes to prevent serious complications from digoxin toxicity.
A client who has just started taking levodopa-carbidopa (Sinemet) for Parkinson's disease reports experiencing nausea. What should the nurse recommend to the client?
- A. Take the medication on an empty stomach.
- B. Consume a low-protein snack with the medication.
- C. Increase your intake of dairy products.
- D. Stop taking the medication and notify your healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Consume a low-protein snack with the medication. This is because levodopa absorption is improved when taken with a low-protein snack, reducing the risk of nausea. Choice A is incorrect as taking the medication on an empty stomach can exacerbate nausea. Choice C is incorrect as increasing dairy intake can interfere with levodopa absorption. Choice D is incorrect as abruptly stopping the medication can worsen Parkinson's symptoms.
The client has undergone a thyroidectomy, and the nurse is providing care. Which assessment finding requires immediate intervention?
- A. Hoarseness and a sore throat.
- B. Difficulty swallowing.
- C. Numbness and tingling around the mouth.
- D. Temperature of 100.2°F (37.9°C).
Correct Answer: C
Rationale: The correct answer is C: Numbness and tingling around the mouth. This finding indicates potential hypocalcemia, a common complication post-thyroidectomy due to inadvertent damage to parathyroid glands. Hypocalcemia can lead to tetany, seizures, and cardiac dysrhythmias. Immediate intervention is needed to prevent serious complications.
Hoarseness and a sore throat (A) are expected post-thyroidectomy due to intubation. Difficulty swallowing (B) can be due to swelling but is not immediately life-threatening. A temperature of 100.2°F (37.9°C) (D) is slightly elevated but not a priority in this scenario.
A client with a history of gout is experiencing an acute attack. Which medication should the nurse expect the healthcare provider to prescribe?
- A. Aspirin.
- B. Allopurinol (Zyloprim).
- C. Colchicine.
- D. Probenecid (Benemid).
Correct Answer: C
Rationale: The correct answer is C: Colchicine. Colchicine is used to treat acute gout attacks by reducing inflammation and pain. It works by decreasing the inflammatory response to urate crystals in the joints. Aspirin (choice A) is not recommended for gout treatment as it can worsen symptoms. Allopurinol (choice B) and Probenecid (choice D) are used for long-term management of gout by reducing uric acid levels and preventing future attacks, not for acute attacks. Colchicine is the appropriate choice for treating the client's acute gout symptoms.