Nokea
Select the term which is most completely and accurately paired with its definition.
- A. A physical restraint: A physical restraint is a manufactured device that is used, when necessary, to prevent falls.
- B. A physical restraint: A physical restraint is any mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
- C. A chemical restraint: A chemical restraint is a drug used for sedation to prevent falls.
- D. A chemical restraint: A chemical restraint is a drug used for discipline or convenience and not required to treat medical symptoms.
Correct Answer: B,D
Rationale: A physical restraint is correctly defined as a device restricting movement that the client cannot easily remove. A chemical restraint is a drug used for discipline or convenience, not for medical symptoms, such as preventing falls .
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The nurse is caring for a client with a history of gastric ulcer who is prescribed sucralfate (Carafate). The nurse should instruct the client to take the medication:
- A. With meals to enhance absorption.
- B. On an empty stomach.
- C. At bedtime only.
- D. With an antacid.
Correct Answer: B
Rationale: Sucralfate should be taken on an empty stomach to coat the gastric mucosa effectively, promoting ulcer healing.
Select the hazard of immobility that is accurately paired with an appropriate expected outcome of care that the nurse provides to prevent this complication.
- A. Bone demineralization: Turning and positioning every 2 hours
- B. Urinary stasis: The client will consume 1,000 mL of oral fluids per day
- C. Muscle atrophy: The client will perform range of motion exercises at least 3 times a day
- D. Hypercalcemia: Maintaining fluid intake of 1,000 mL per day
Correct Answer: C
Rationale: Range of motion exercises prevent muscle atrophy by maintaining muscle strength and function in immobile clients.
A client with a history of type 2 diabetes mellitus is prescribed sitagliptin (Januvia). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Pancreatitis.
- C. Hypertension.
- D. Weight gain.
Correct Answer: B
Rationale: Sitagliptin can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.
The nurse is assessing a client with a suspected diverticulitis. Which of the following findings is most indicative of this condition?
- A. Left lower quadrant pain.
- B. Right upper quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Left lower quadrant pain is a hallmark sign of diverticulitis due to inflammation of diverticula in the sigmoid colon.
A client with a history of chronic lymphocytic leukemia is prescribed prednisone. The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Weight gain.
- C. Hypotension.
- D. Hair loss.
Correct Answer: B
Rationale: Prednisone, a corticosteroid, commonly causes weight gain due to fluid retention and increased appetite.