Nokea
The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?
- A. Diabetes
- B. Prinzmetal's angina
- C. Cancer
- D. Cluster headaches
Correct Answer: B
Rationale: Prinzmetal's angina is a contraindication for sumatriptan due to the risk of coronary vasospasm, and this should be reported to the doctor.
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A nurse creates a care plan for a client diagnosed with a cerebellar brain tumor. The correct nursing diagnosis for this client is 'Client at risk for injury related to
- A. impaired balance.'
- B. decreased visual acuity.'
- C. decreased level of consciousness.'
- D. impaired ability to make decisions.'
Correct Answer: A
Rationale: Cerebellar tumors impair coordination and balance, increasing fall risk, making 'impaired balance' the most relevant diagnosis.
A labor and delivery nurse is assessing a newborn baby boy. Which finding would indicate possible microcephaly?
- A. depressed fontanelles during feeding
- B. hypoactivity
- C. head circumference in lowest tenth percentile
- D. absent fontanelles
Correct Answer: C
Rationale: Microcephaly is defined by a head circumference significantly below normal (e.g., lowest 10th percentile), indicating potential brain development issues.
If a client has had repair of a right fractured hip and has an overhead trapeze on the bed to assist with movement, which of the following instructions should the client receive about use of the assistive device? Select all that apply.
- A. The client should always grasp the bar with both hands before moving.
- B. The client should grasp the bar with the left hand and place the right hand flat on the bed to assist movement.
- C. The client should flex the left hip and knee and place the foot flat on the bed before moving.
- D. The client should keep the left hip and knee extended when moving.
Correct Answer: A,C
Rationale: Using both hands on the trapeze (A) and flexing the left leg (C) assist safe movement post-right hip repair. Using one hand (B) or keeping the leg extended (D) is less effective.
A client develops mastitis in the postpartum period. Which of the following instructions does the nurse anticipate when notifying the physician? Select all that apply.
- A. Antibiotics for 7 to 10 days.
- B. Opioid analgesia.
- C. Alternating hot and cold compresses to relieve the pain.
- D. Discontinuation of breastfeeding.
- E. Continuation of breastfeeding.
Correct Answer: A,C,E
Rationale: Mastitis is typically treated with antibiotics (A) for 7-10 days to address the infection. Alternating hot and cold compresses (C) can help relieve pain and reduce inflammation. Continuation of breastfeeding (E) is encouraged to promote milk flow and prevent further complications, unless contraindicated. Opioid analgesia (B) is not typically required, and discontinuation of breastfeeding (D) is not recommended as it may worsen the condition.
A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client's vital signs that include:
- A. Decreased pulse rate
- B. Increased blood pressure
- C. Decreased respiratory rate
- D. Increased temperature
Correct Answer: B
Rationale: Severe pain from renal calculi can cause increased blood pressure due to sympathetic nervous system activation and stress response.