Nokea
The emergency department nurse is assessing a client who abruptly discontinued benzodiazepine therapy and is experiencing withdrawal. Which manifestations of withdrawal should the nurse expect to note? Select all that apply.
- A. Tremors
- B. Sweating
- C. Lethargy
- D. Agitation
- E. Nervousness
- F. Muscle weakness
Correct Answer: A,B,D,E
Rationale: Benzodiazepines should not be abruptly discontinued because withdrawal symptoms are likely to occur. Withdrawal symptoms include tremor, sweating, agitation, nervousness, insomnia, anorexia, and muscular cramps. Withdrawal symptoms from long-term, high-dose benzodiazepine therapy include paranoia, delirium, panic, hypertension, and status epilepticus. Lethargy is not associated with benzodiazepine withdrawal.
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An assessment of a client's vocal cords requires indirect visualization of the larynx. Which instruction should the nurse give the client to facilitate this procedure?
- A. Try to swallow.
- B. Hold your breath.
- C. Breathe normally.
- D. Roll the tongue to the back of the mouth.
Correct Answer: C
Rationale: Indirect laryngoscopy is done to assess the function of the vocal cords or obtain tissue for biopsy. Observations are made during rest and phonation by using a laryngeal mirror, head mirror, and light source. The client is placed in an upright position to facilitate passage of the laryngeal mirror into the mouth and is instructed to breathe normally. Swallowing cannot be done with the mirror in place. The procedure takes longer than the time the client would be able to hold the breath, and this action is ineffective anyway. The tongue cannot be moved back because it would occlude the airway.
The nurse is monitoring a client who was recently prescribed total parenteral nutrition (TPN). Which action should the nurse take when obtaining a fingerstick glucose reading of 425 mg/dL (24.28 mmol/L)?
- A. Stop the TPN.
- B. Administer insulin.
- C. Notify the primary health care provider.
- D. Decrease the flow rate of the TPN.
Correct Answer: C
Rationale: Hyperglycemia is a complication of TPN, and the nurse should report abnormalities to the primary health care provider. Options 1, 2, and 4 are not done without a primary health care provider's prescription.
A child is admitted to the hospital with a diagnosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which finding will confirm the likelihood of this disorder?
- A. Increased leukocyte count
- B. Decreased hemoglobin count
- C. Increased antistreptolysin-O (ASO titer)
- D. Decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the presence of rheumatic fever. The remaining options are unrelated to diagnosing rheumatic fever. Additionally, an increased leukocyte count indicates the presence of infection but is not specific in confirming a particular diagnosis.
The nurse caring for a child admitted to the hospital with a diagnosis of viral pneumonia describes the treatment plan to the parents. The nurse determines the need for further teaching when the parents make which statement regarding the treatment?
- A. We need to be very careful since oxygen is extremely flammable.
- B. It's important that the child isn't allergic to the antibiotic that is prescribed.
- C. It's difficult to watch the needle be inserted when intravenous fluids are needed.
- D. Chest physiotherapy will loosen the congestion, so coughing will clear the lungs.
Correct Answer: B
Rationale: The therapeutic management for viral pneumonia is supportive. Antibiotics are not given unless the pneumonia is bacterial. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and intravenous fluids.
A client diagnosed with diabetes mellitus receives 8 units of regular insulin subcutaneously at 7:30 am. The nurse should be most alert to signs of hypoglycemia at what time during the day?
- A. 9:30 am to 11:30 am
- B. 11:30 am to 1:30 pm
- C. 1:30 pm to 3:30 pm
- D. 3:30 pm to 5:30 pm
Correct Answer: A
Rationale: Regular insulin is a short-acting insulin. Its onset of action occurs in a half hour and peaks in 2 to 4 hours. Its duration of action is 4 to 6 hours. A hypoglycemic reaction will most likely occur at peak time, which in this situation is between 9:30 am and 11:30 am.