Nokea
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking 'the blue pill' (haloperidol) in the morning and evening, and 'the white pill' (benztropine) right before bedtime. The nurse might suggest to the client that she try:
- A. Doubling the daily dose of benztropine
- B. Decreasing the haloperidol dosage for a few days
- C. Taking the benztropine in the morning
- D. Taking her medication with food or milk
Correct Answer: C
Rationale: Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. This response is an appropriate independent nursing action. Because motor restlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.
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A client is placed on lithium therapy for her manic-depressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
- A. 1.0 mEq/L
- B. 2.2 mEq/L
- C. 0.03 mEq/L
- D. 1.5 mEq/L
Correct Answer: D
Rationale: This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
- A. Prolonged bed rest
- B. The client's maintaining a semi-Fowler position
- C. Cerebral hypoxia
- D. IV fluids of 2.5-3 liters in 24 hours
Correct Answer: C
Rationale: Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.
A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?
- A. pH 7.39
- B. White blood cell (WBC) count 10,000 WBCs/mm3
- C. Hematocrit 60%
- D. Bleeding time of 4 minutes
Correct Answer: C
Rationale: Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease.
The registered nurse is making assignments for the day. Which client should be assigned to the nurse who is pregnant?
- A. The client with HIV treated with Pentam (pentamidine)
- B. The client with cervical cancer treated with a radium implant
- C. The client with RSV treated with Virazole (ribavirin)
- D. The client with cytomegalovirus treated with Valcyte (valganciclovir)
Correct Answer: D
Rationale: Valganciclovir for cytomegalovirus poses minimal risk to a pregnant nurse as it is not teratogenic and standard precautions suffice. Pentamidine ribavirin and radium implants carry higher risks due to potential teratogenicity or radiation exposure.
A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the client's inpatient stay, which expected outcome is most appropriate?
- A. He will attend four consecutive group educational sessions on substance abuse.
- B. He will name activities that he would most likely be involved in posttreatment.
- C. He will meet with his family in counseling sessions and discuss his feelings.
- D. He will be able to deal with his feelings through participation in group therapy sessions.
Correct Answer: D
Rationale: This expected outcome is specific as related to attendance, but not specific as related to outcome criteria. Stating activities does not guarantee involvement. This goal may help the recovery process, but post counseling behavior is not addressed. This statement best describes the expected outcome. The client will be attending group therapy sessions and through them he will deal with his feelings.