Nokea
The client has been prescribed clonidine for the unlabeled purpose of easing the discomfort associated with smoking cessation. Which body system should be the nurse's initial focus when completing the client's physical assessment?
- A. Neurological
- B. Cardiovascular
- C. Gastrointestinal
- D. Musculoskeletal
Correct Answer: B
Rationale: Clonidine (Catapres) can cause hypotension and bradycardia, making the cardiovascular system the initial focus.
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The 30-year-old has been taking olanzapine for the past 5 years for the treatment of schizophrenia. The client, who has a positive family history of DM, is now overweight but is not showing signs of hyperglycemia. When the client asks about the next steps for treatment, how should the nurse respond?
- A. You'll be started on an oral hyperglycemic agent.
- B. I will be teaching you how to self-administer insulin.
- C. You'll need to have a fasting blood glucose level drawn.
- D. Olanzapine will be discontinued and another drug started.
Correct Answer: C
Rationale: Due to the risk of hyperglycemia with olanzapine (Zyprexa), blood glucose testing is needed to determine if medication therapy is indicated.
The hospitalized adult is having difficulty falling and staying asleep. The nurse consults standing orders, which have medications included in the table illustrated. Which hypnotic medication should the nurse administer to effectively help the client sleep soundly throughout the night?
- A. Zaleplon
- B. Triazolam
- C. Flurazepam
- D. Eszopiclone
Correct Answer: B
Rationale: Triazolam (Halcion) has a later peak and longer duration, helping the client fall and stay asleep longer.
The client taking sertraline for treatment of depression for the past 11 months reports feeling much better and wishes to discontinue the medication. Which is the nurse's most appropriate response?
- A. The medication will have to be reduced gradually to prevent undesirable symptoms.
- B. You should not stop the medication without talking to your health care provider first.
- C. It appears that the medication has worked very well. It should be safe to discontinue its use.
- D. You should take this medication indefinitely to prevent recurrence of depressive symptoms.
Correct Answer: A
Rationale: Sertraline (Zoloft) is an SSRI antidepressant. Stopping these abruptly can cause withdrawal symptoms. The dose should be reduced gradually.
The 5-year-old is receiving an IV infusion of D5 with 0.45 NaCl at 100 mL/hr. Which assessment findings suggest excessive parenteral fluid intake? Select all that apply.
- A. Dyspnea
- B. Lethargy
- C. Gastric distention
- D. Crackles in lung bases
- E. Temperature of 102°F (38.9°C)
Correct Answer: A,B,D
Rationale: A: Dyspnea indicates fluid volume overload and occurs from fluid rapidly shifting between the intracellular and extracellular compartments. B: Lethargy and change in level of consciousness can occur from fluid shifting in brain cells. C: Gastric distention can occur from excessive oral (not IV) fluid intake or infection. D: Crackles indicate fluid volume overload and occur from fluid rapidly shifting into the alveoli. E: An elevated temperature is a sign of fluid volume deficit, not excess.
Which of the following is an inappropriate item to include in planning care for a severely neutropenic client?
- A. Transfuse netrophils (granulocytes) to prevent infection.
- B. Exclude raw vegetables from the diet.
- C. Avoid administering rectal suppositories.
- D. Prohibit vases of fresh flowers and plants in the client's room.
Correct Answer: A
Rationale: Granulocyte transfusion is not indicated to prevent infection. Produced in the bone marrow, granulocytes normally comprise 70% of all WBCs. They are subdivided into three types based on staining properties: neutrophils, eosinophils, and basophils. They can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production.