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The client with CP is taking dantrolene. The nurse evaluates that the medication is effective when noting that the client has an increase in which findings? Select all that apply.
- A. Muscle spasticity
- B. Urinary frequency
- C. Level of mobility
- D. Ability to maintain balance
- E. Level of alertness
Correct Answer: C,D
Rationale: A: Increased muscle spasticity indicates the medication is not effective. B: Common adverse effects include urinary frequency. C: Dantrolene acts directly on skeletal muscles to inhibit muscle contraction, improving mobility. D: Dantrolene acts directly on skeletal muscles to inhibit muscle contraction, improving the ability to maintain balance. E: Dantrolene does not increase alertness.
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The client with Addison's disease is taking fludrocortisone 100 mcg orally once daily. Which statement made by the client regarding the fludrocortisone therapy requires further teaching by the nurse?
- A. I should talk to my health care provider about getting a flu shot this year.
- B. I should stop taking fludrocortisone if my blood sugar levels are too high.
- C. I should check my weight, blood pressure, and pulse once every morning.
- D. I should eat foods higher in potassium like bananas, melons, and pears.
Correct Answer: B
Rationale: A: The client should check with the HCP about getting vaccinations such as influenza; a chronic condition increases the client's risk for other illnesses and complications. B: The client needs further teaching if stating that he or she will stop taking fludrocortisone (Florinef) if his or her blood sugar levels are too high; stopping mineralocorticoid replacement therapy abruptly may lead to addisonian crisis. C: Common adverse effects of fludrocortisone include edema, arrhythmias, and hypertension; stating that he or she should monitor weight, BP, and pulse daily is appropriate. D: Common adverse effects of fludrocortisone include hypokalemia; stating that he or she should consume potassium-rich foods is appropriate.
The nurse is caring for a client who has dysphagia related to a stroke. The nurse works with the client to explain what food and beverages might minimize aspiration. What is this an example of?
- A. health promotion
- B. secondary prevention
- C. tertiary prevention
- D. primary prevention
Correct Answer: C
Rationale: The goal of tertiary prevention is to improve quality of life while minimizing further injury or symptoms of chronic disease. Primary prevention is used to prevent disease. Secondary prevention focuses on early detection of disease and interventions to prevent worsening of that disease. Health promotion activities are designed to prevent illness and promote wellness.
The nurse is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?
- A. I am nervous about how painful labor will be.
- B. I need to review my finances and make sure I am prepared to care for a child.
- C. I hate this nausea that I've been having for a week.
- D. I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent.
Correct Answer: D
Rationale: The nurse should follow up on the client's lack of support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea.
The nurse is preparing to administer the client's medication for treatment of TB. Which medication, if on the client's MAR, should the nurse plan to administer?
- A. Isoniazid
- B. Fluconazole
- C. Azithromycin
- D. Acyclovir
Correct Answer: A
Rationale: A: Isoniazid (INH) is an antimycobacterial medication affecting bacterial cell wall synthesis; it is used in the treatment of TB or other mycobacterial infections. B: Fluconazole (Diflucan) is an antifungal agent that inhibits synthesis of fungal sterols, a necessary component of the cell membrane. C: Azithromycin (Zithromax) is a macrolide antibiotic that is bacteriostatic against susceptible bacteria and is usually used for treating lower respiratory tract infections, skin infections, acute otitis media, tonsillitis, or Mycobacterium avium. D: Acyclovir (Zovirax) is an antiviral agent limited to treatment of herpes viruses.
The LPN receives a call from a mother caring for her eight-month-old infant. The mother describes that the child has a low-grade fever and has teeth breaking through the gums. Which of the following measures would be inappropriate to recommend to the mother?
- A. Allow the child to chew on a cooled teething ring.
- B. Massage the child's gums gently.
- C. Administer acetaminophen.
- D. Administer aspirin.
Correct Answer: D
Rationale: Aspirin should not be recommended as a pain medication for children due to the increased risk of Reye's syndrome.