Nokea
Ergotamine tartrate (Gynergen) is prescribed for a client's migraine headaches. The client's report of which of the following indicates effectiveness?
- A. Prevention of the migraine.
- B. Reduced severity of the developing migraine.
- C. Relief from the sleeplessness experienced in the past after a migraine.
- D. Relief from the vision problems experienced in the past after a migraine.
Correct Answer: B
Rationale: Ergotamine reduces the severity of developing migraines by constricting cranial blood vessels. It is not primarily preventive or used for post-migraine sleeplessness or vision issues.
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The nurse is observing a student nurse administer eyedrops, as shown in the fi gure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client’s eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.
The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate?
- A. Peripheral edema.
- B. Ascites.
- C. Anorexia.
- D. Jaundice.
Correct Answer: D
Rationale: Jaundice (D) is a common early sign of cirrhosis due to impaired bilirubin metabolism. Peripheral edema (A) and ascites (B) occur later. Anorexia (C) is less specific.
A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed to avoid wrong-site surgery? Select all that apply.
- A. Ask the surgeon preoperatively to mark with a permanent marker the correct knee for the surgical site.
- B. Verbally ask the client to state his name, surgical site, and procedure.
- C. Verify the correct client with the correct operative site by medical records and radiographic diagnostic reports.
- D. Call a 'time-out' in the operating room to have the surgeon verify the correct knee before making the incision.
- E. Show the client an anatomic model of the surgery site.
Correct Answer: A,B,C,D
Rationale: To prevent wrong-site surgery, the surgeon marks the site (A), the client verifies identity and procedure (B), records are checked (C), and a time-out confirms the site (D). Showing a model (E) is educational but not a standard safety measure.
The nurse assesses a client with a below-knee amputation for prosthetic fitting. Which finding indicates readiness for a prosthesis?
- A. Full range of motion in the residual limb.
- B. Absence of pain in the stump.
- C. Healed incision with no drainage.
- D. Presence of mild edema in the stump.
Correct Answer: C
Rationale: A healed incision without drainage is essential for safe prosthetic fitting to prevent skin breakdown.
In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, the nurse should instruct the client to:
- A. Keep the hands and feet elevated as much as possible
- B. Use a vibrating massage device on the hands
- C. Wear gloves when obtaining food from the refrigerator
- D. Increase coffee intake to 2 cups per day
Correct Answer: C
Rationale: Wearing gloves when obtaining food from the refrigerator prevents cold-triggered vasospasm in Raynaud's. Elevation is irrelevant, vibrating devices may worsen symptoms, and coffee (caffeine) can cause vasoconstriction, increasing episodes.