Nokea
The client prescribed phenelzine sulfate suddenly exhibits signs of hypertensive crisis. Which medication should the nurse plan to prepare?
- A. Vitamin K
- B. Phentolamine
- C. Protamine sulfate
- D. Calcium gluconate
Correct Answer: B
Rationale: The manifestations of hypertensive crisis include hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The antidote for hypertensive crisis is phentolamine and a dosage by intravenous injection is administered. Protamine sulfate is the antidote for heparin. Calcium gluconate is used for magnesium overdose. Phytonadione is the antidote for warfarin overdose.
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The nurse is planning a program about women's health and cancer prevention for a community health fair. The nurse should include information about? Select all that apply.
- A. Regular self-exams of the breast and vulva are important self-care activities.
- B. Cancer can be prevented by removing precancerous lesions of the vulva, cervix, or endometrium.
- C. Girls, age 11 to 12, should receive immunization for human papilloma virus (HPV) to prevent cervical cancer.
- D. Smoking cessation reduces the risk of cervical cancer.
- E. There is limited evidence that cancer in women is inherited.
Correct Answer: A,B,C
Rationale: Self-exams, removal of precancerous lesions, and HPV vaccination are key prevention strategies. Smoking cessation reduces lung cancer risk, not cervical. Some cancers have genetic links.
A client with a history of anxiety is prescribed buspirone (Buspar). The nurse should teach the client that the medication:
- A. Takes 2 to 4 weeks to be effective
- B. Causes immediate sedation
- C. Is taken as needed for panic attacks
- D. May cause weight loss
Correct Answer: A
Rationale: Buspirone requires 2 to 4 weeks to achieve therapeutic effects for anxiety, unlike benzodiazepines, which act quickly.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen flow to 4 L/min.
- B. Notify the physician immediately.
- C. Encourage the client to perform deep breathing exercises.
- D. Reposition the client to a high Fowler's position.
Correct Answer: D
Rationale: Repositioning to a high Fowler's position optimizes lung expansion and improves oxygenation, which is the first non-invasive intervention to try for a COPD client with low oxygen saturation.
Select all of the cranial nerves that are accurately paired with its distinguishing characteristics and description. Again, select all that apply.
- A. Olfactory Cranial Nerve: The sensory nerve that transmits the sense of smell to the olfactory foramina of the nose
- B. Optic Cranial Nerve: This sensory nerve transmits the sense of vision from the retina to the brain.
- C. Oculomotor Cranial Nerve: This motor and sensory nerve controls eye movements and visual acuity.
- D. Trochlear Cranial Nerve: This motor nerve innervates eye ball movement and the superior oblique muscle of the eyes.
- E. Abducens Cranial Nerve: This motor nerve innervates and controls the abduction of the eye using the lateral rectus muscle.
- F. Facial Cranial Nerve: This motor nerve controls facial movements, some salivary glands and gustatory sensations from the anterior part of the tongue.
- G. Glossopharyngeal Cranial Nerve: This sensory nerve This nerve gives us the sense of taste from the posterior tongue, and it also innervates the parotid glands
Correct Answer: A,B,D,E,F
Rationale: Options A, B, D, E, and F are correct. The olfactory nerve (I) is sensory for smell, the optic nerve (II) is sensory for vision, the trochlear nerve (IV) is motor for the superior oblique muscle, the abducens nerve (VI) is motor for the lateral rectus muscle, and the facial nerve (VII) is both motor and sensory, controlling facial movements and taste from the anterior tongue. Option C is incorrect because the oculomotor nerve (III) does not control visual acuity, and option G is incorrect because the glossopharyngeal nerve (IX) is both sensory and motor, not purely sensory.
A client has his leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment?
- A. Inability to move toes.
- B. Cyanosis of toes.
- C. Complaints of cast tightness.
- D. Tingling of toes.
Correct Answer: D
Rationale: Tingling is an early sign of circulatory impairment due to nerve compression from swelling or tight casting, requiring prompt attention.