Nokea
The client is prescribed prednisone for an acute exacerbation of lupus. Which side effect should the nurse monitor for?
- A. Hypoglycemia
- B. Weight loss
- C. Hypertension
- D. Bradycardia
Correct Answer: C
Rationale: Prednisone, a corticosteroid, can cause hypertension due to sodium retention and vasoconstriction. Hyperglycemia (not hypoglycemia), weight gain, and tachycardia are more likely than weight loss or bradycardia.
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A female client at 30 weeks' gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?
- A. Abruptio placentae
- B. Ectopic pregnancy
- C. Massive uterine rupture
- D. Placenta previa
Correct Answer: A
Rationale: Abruptio placentae, the complete or partial separation of the placenta from the uterine wall, can be caused by external trauma. When hemorrhage is concealed, one sign is a rapid increase in uterine size with rigidity. Ectopic pregnancy occurs when the embryo implants itself outside the uterine cavity. Massive uterine rupture occurs during labor when the uterine contents are extruded through the uterine wall. It is usually due to weakness from a pre-existing uterine scar and trauma from instruments or an obstetrical intervention. Placenta previa is the condition in which the placenta is implanted in the lower uterine segment and either completely or partially covers the cervical os.
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.
A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?
- A. I understand you're depressed, but killing yourself is not a reasonable option.'
- B. We need to discuss this further, but right now let's complete these forms.'
- C. Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one.'
- D. This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff.'
Correct Answer: D
Rationale: To the client, suicide may be a reasonable action and the only one he can cope with at this time. This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.
A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
- A. I will keep candy with me just in case my blood sugar drops.'
- B. I need to stay out of the sun as much as possible.'
- C. I often skip dinner because I don't feel hungry.'
- D. I always wear my medical identification.'
Correct Answer: C
Rationale: Skipping meals, like dinner, can cause hypoglycemia in patients on glyburide, a sulfonylurea that stimulates insulin release. Keeping candy for hypoglycemia, avoiding sun (due to photosensitivity), and wearing ID are correct.
Which of the following statements applies to the care of the client hospitalized with influenza?
- A. The nurse should wear an N-95 mask when caring for the client.
- B. The client may cohort with another client hospitalized with the same diagnosis.
- C. Equipment used in the client's care should remain in the room until the client is discharged.
- D. The door to the client's room may remain open to the hallway.
- E. The nurse should wear a mask when direct care of the client is required.
Correct Answer: B, C, E
Rationale: Influenza requires droplet precautions: cohorting with same diagnosis (B), keeping equipment in the room (C), and wearing a mask for direct care (E). N-95 masks (A) are for airborne diseases (e.g., TB). The door should remain closed (D) to limit droplet spread.