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The client is taking streptomycin, isoniazid, and rifampin (Rimactane). Which statement indicates toxicity to isoniazid?
- A. My ears ring all the time.
- B. I have sharp pains in my legs.
- C. My urine is orange-colored.
- D. I'm having trouble at traffic lights.
Correct Answer: B
Rationale: Isoniazid can cause peripheral neuropathy, manifesting as sharp leg pains. Tinnitus is linked to streptomycin, orange urine to rifampin, and color vision issues are unrelated.
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One hour after receiving 7 U of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. The priority nursing action would be to
- A. notify the physician.
- B. call the lab for a blood glucose level.
- C. offer the client milk and crackers.
- D. administer glucagon.
Correct Answer: C
Rationale: Diaphoresis, pallor, and tachycardia indicate hypoglycemia, a medical emergency. Milk and crackers provide fast-acting carbohydrates. Options A, B, and D delay treatment or are reserved for severe cases.
The nurse is caring for a client who is postoperative day 1 after a prostatectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Blood-tinged urine.
- D. Urine output of 200 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-prostatectomy complication. Options A, C, and D are normal.
A low-purine diet is ordered for a client who has uric acid kidney stones. Which foods should the client avoid? Select all that apply.
- A. Eggs
- B. Chicken
- C. Liver
- D. Oats
- E. Lentils
- F. Lobster
Correct Answer: C,F
Rationale: Liver and lobster are high-purine foods, increasing uric acid production, which worsens uric acid kidney stones. Eggs, chicken, oats, and lentils are lower in purines and safer.
The nurse is caring for a woman who is admitted following a beating by her husband. The woman says, 'It wasn't really his fault. Dinner was late.' The husband arrives to visit his wife with a large bouquet of flowers and a box of chocolates. The woman later says to the nurse, 'He feels so bad about what he did and says it will never happen again.' What concept should guide the nurse when replying to the client?
- A. Men who abuse their wives and then repent usually do not do it again.
- B. The woman is quite perceptive and should be safe when she is discharged.
- C. Abuse is often followed by repentance and then again by abuse.
- D. Spousal abuse is usually a result of misbehavior on the part of the abused.
Correct Answer: C
Rationale: The cycle of abuse often includes remorse followed by repeated abuse, guiding the nurse to educate about patterns, not assume safety or blame the victim.
A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client is using the mechanism of 'suppression'?
- A. I don't remember anything about what happened to me.
- B. I'd rather not talk about it right now.
- C. It's all the other guy's fault! He was going too fast.
- D. My mother is heartbroken about this.
Correct Answer: A
Rationale: I don't remember anything about what happened to me. Suppression is willfully putting an unacceptable thought or feeling out of one's mind, used to protect one's self-esteem.