Nokea
Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about
- A. Mental development delays
- B. Evil eye or envy of others
- C. Fright from spiritual beings
- D. Balance in body systems
Correct Answer: B
Rationale: Evil eye or envy of others. In Greek culture, amulets protect against 'matiasma' or the evil eye, especially for children.
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The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Dry mouth.
- C. Suicidal thoughts.
- D. Insomnia.
Correct Answer: C
Rationale: Suicidal thoughts are a medical emergency with venlafaxine. Options A, B, and D are common side effects.
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix) 40 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Glucose 100 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (3.0 mEq/L) from furosemide increases arrhythmia risk in heart failure. Options B, C, and D are normal.
A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse?
- A. Para 2, Gravida 1
- B. Nulligravida 2, Para 1
- C. Primigravida 1, Para 1
- D. Gravida 2, Para 1
Correct Answer: D
Rationale: Gravida 2, Para 1. Gravida describes a woman who is or has been pregnant, regardless of pregnancy outcome. Para describes the number of babies born past a point of viability.
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
- A. Tinnitus
- B. Tachycardia
- C. Ataxia
- D. Hypotension
Correct Answer: B
Rationale: Tachycardia is a common side effect of bronchodilators, such as beta-agonists, due to their stimulatory effect on the sympathetic nervous system.
The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment?
- A. Heart rate
- B. Neurologic status
- C. Urine output
- D. Blood pressure
Correct Answer: D
Rationale: The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.