Nokea
The client using latanoprost eye drops for treatment of glaucoma calls the ophthalmology clinic after noting a brown pigmentation of the iris. Which nursing action is most appropriate?
- A. Instruct the client to come to the clinic to have the eyes and medication evaluated.
- B. Schedule an appointment for the client to see an internist for liver function studies.
- C. Tell the client that the pigmentation is from the latanoprost but will eventually regress.
- D. Recommend that the client wear sunglasses when outdoors to decrease iris pigmentation.
Correct Answer: A
Rationale: A: A side effect of latanoprost (Xalatan), a prostaglandin, includes a heightened brown pigmentation of the iris, which stops progressing when latanoprost is discontinued. B: Jaundiced sclera, and not brown iris pigmentation, would suggest the need to evaluate liver function. C: The brown iris pigmentation from the latanoprost does not usually regress. D: Wearing sunglasses will have no effect on the iris pigmentation.
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The nurse is assessing the client. Which findings indicate that the client may be experiencing physical changes from long-term use of prednisone? Select all that apply.
- A. Weight gain
- B. Increased muscle mass
- C. Fragile skin
- D. Acne vulgaris
- E. Alopecia
Correct Answer: A,C,D
Rationale: A: Weight gain and muscle atrophy are body changes that may occur with long-term glucocorticoid therapy. B: Muscle wasting (not increased muscle mass) is a side effect of prednisone. C: Fragile skin is a possible body change that may occur with long-term glucocorticoid therapy. D: Acne vulgaris may occur with long-term glucocorticoid therapy. E: Hirsutism (not alopecia) is a side effect of prednisone.
Following a THR, the client asks the nurse, “Why am I receiving enoxaparin? With my last hip surgery, I was given a heparin injection.†What is the nurse's best response?
- A. Enoxaparin is less expensive for you and much easier to administer than the heparin.
- B. There is less risk of bleeding with enoxaparin, and it doesn't affect your laboratory results.
- C. Enoxaparin is a low-molecular-weight heparin that lasts twice as long as regular heparin.
- D. Enoxaparin can be administered orally, whereas heparin is administered only by injection.
Correct Answer: C
Rationale: A: The cost of enoxaparin is more than twice the cost of the equivalent dose of heparin per injection. Both are available in prefilled syringes for subcutaneous injection. B: Both enoxaparin and heparin increase aPTT, which affects clotting. C: Because enoxaparin is more specific in inhibiting active factor X, the response is more stable, and the effect is two to four times longer than that of heparin. D: Enoxaparin is only administered subcutaneously. Heparin can be administered both subcutaneously and intravenously.
The new nurse asks the experienced nurse why the first dose of the MMR vaccine is normally given at 12 to 15 months of age and not earlier, except with international travel. Which explanation by the experienced nurse is correct?
- A. Giving the first dose of the vaccine at 12 to 15 months of age allows the correct interval before the next booster at age 12 years.
- B. A live virus is being given; the chance of measles, mumps, or rubella developing is much higher if given at an earlier age.
- C. A first dose at this age provides passive immunity and decreases the incidence of a child developing any of the diseases.
- D. If given earlier, the vaccine may neutralize the passive immunity to measles from the child's mother and no immunity may result.
Correct Answer: D
Rationale: A: The second dose of the MMR vaccine can be given earlier, provided that at least 4 weeks has elapsed since the first dose. However, a second dose is usually not given earlier because sufficient immunity is usually present. B: The chance of developing only measles is greater if the vaccine is given at a younger age because the vaccine may neutralize the passive antibodies. C: The MMR provides active (not passive) immunity. D: Because the MMR vaccine is a live virus, a person develops a mild form of the diseases after administration, stimulating the body to develop immunity. The passively acquired antibodies to measles can interfere with the child's immune response to the vaccine, and no immunity may result.
The nurse is assessing the laboratory test results for the male client receiving testosterone replacement therapy for treatment of hypogonadism. Which laboratory test result is most important for the nurse to review?
- A. Fasting lipid profile
- B. Partial thromboplastin time
- C. Urinalysis
- D. Serum potassium
Correct Answer: A
Rationale: A: The most important test is the fasting lipid profile because testosterone can lower plasma levels of HDLs and elevate plasma levels of LDLs, increasing the risk of atherosclerosis. B: Testosterone has little effect on PTT. C: Testosterone has little effect on urine. D: Testosterone has little effect on serum potassium.
Which of the following statements is correct about Maslow's hierarchy of needs?
- A. There are psychosocial interventions that may be applicable to all of the levels.
- B. There are physical interventions that may be applicable to all of the levels.
- C. Two of the levels may require physical intervention while four of the levels may require psychosocial intervention.
- D. Four of the levels may require physical intervention, while two of the levels may require psychosocial intervention.
Correct Answer: C
Rationale: In Maslow's hierarchy of needs, two of the levels, physiological needs and safety and security needs, may require physical interventions. Four of the levels, safety and security needs, love and belonging needs, self-esteem needs, and self-actualization needs may require psychosocial intervention. Safety and security needs may require physical or psychosocial intervention.