Nokea
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.
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Which client statement indicates a need for further teaching about warfarin therapy?
- A. I'll avoid eating large amounts of spinach.'
- B. I'll take my medication at the same time daily.'
- C. I can take ibuprofen for headaches.'
- D. I'll report any unusual bruising.'
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk with warfarin; the client should use acetaminophen instead.
The nurse assessed the client newly diagnosed with MG. Which finding should the nurse recognize as being unrelated to the diagnosis?
- A. Drooping eyelids
- B. Slurred speech
- C. Weak lower extremities
- D. Circumoral tingling
Correct Answer: D
Rationale: Ptosis (drooping eyelids) is a sign of muscle weakness often seen with MG. If the muscles involved with speech are weak in the client with MG, the client may exhibit slurred speech. Clients with MG may demonstrate weakness in the lower extremities. Numbness around the mouth is not associated with muscle weakness but could be indicative of a calcium deficiency or some other problem.
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?
- A. Discuss how to correctly remove the insertion pins.
- B. Instruct the client to report reddened or irritated skin areas.
- C. Inform the client that the vest liner cannot be changed.
- D. Encourage the client to remain in the recliner as much as possible.
Correct Answer: B
Rationale: Skin integrity under a halo device is critical. Instructing to report reddened or irritated skin (B) prevents pressure ulcers. Removing pins (A) is done by providers, the vest liner can be changed (C), and prolonged recliner use (D) risks immobility complications.
Which discharge instruction is most important for a client with a herniated disk?
- A. Sleep on a soft mattress.
- B. Perform high-impact exercises.
- C. Maintain proper body mechanics.
- D. Take hot baths daily.
Correct Answer: C
Rationale: Proper body mechanics prevent re-injury and promote healing in clients with a herniated disk.
What nursing approach is best when managing the care of a client with dementia who insists on carrying a purse at all times?
- A. Ask the client where the purse can be stored.
- B. Take the purse and give it to the family.
- C. Inform the client that the purse may become lost.
- D. Find out why the client feels the need for a purse.
Correct Answer: D
Rationale: Understanding the client's need to carry a purse addresses emotional or security needs, improving care and reducing distress.