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The home care nurse visits a client who started wandering around at 10:00 pm each evening and got out of the house for the first time last night. The family asks for help. Which therapeutic response should the nurse make to the family?
- A. What prevented her from leaving the house in the past?
- B. You cannot handle this alone because she could get hurt.
- C. I think you need to consider a nursing home immediately.
- D. This is a common problem known as sundowner's syndrome.
Correct Answer: A
Rationale: The nurse responds to the family by assessing the situation and collecting additional data regarding the change in the client's behavior. The best response focuses on the family's problem so that the nurse can help develop potential strategies. Option 2 is giving advice. Option 3 is histrionic, invalidates the family's attempt to manage the client's care, and potentially causes resentment. Option 4 provides the nurse's conclusion based on an incomplete assessment; other factors may be causing confusion.
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A client has primary health care provider instructions to take ibuprofen 0.4 g for mild pain. The medication bottle contains ibuprofen 200-mg tablets. How many tablets will the nurse instruct the client to take for each dose? Fill in the blank. tablets
Correct Answer: 2
Rationale: To determine the number of tablets, divide the prescribed dose by the strength per tablet: 0.4 g = 400 mg; 400 mg ÷ 200 mg per tablet = 2 tablets. Therefore, the nurse instructs the client to take 2 tablets per dose.
The nurse is teaching a client with a new diagnosis of asthma about self-management. Which of the following instructions should be included?
- A. Use a peak flow meter daily.
- B. Avoid exercise to prevent attacks.
- C. Take bronchodilators daily.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Daily peak flow meter use monitors lung function and guides asthma management.
A client with a history of depression is prescribed sertraline (Zoloft). The nurse should teach the client to report which side effect?
- A. Weight loss
- B. Increased appetite
- C. Suicidal thoughts
- D. Dry skin
Correct Answer: C
Rationale: Suicidal thoughts are a serious side effect of SSRIs like sertraline, especially in the early weeks, requiring immediate reporting to ensure client safety.
A client has been prescribed metoprolol for hypertension. The nurse monitors client compliance carefully because of which common side effect of the medication?
- A. Impotence
- B. Mood swings
- C. Increased appetite
- D. Complete atrioventricular (AV) block
Correct Answer: A
Rationale: A common side effect of beta-adrenergic blocking agents, such as metoprolol, is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects occur rarely and include mental status changes, nervousness, depression, and insomnia. Mood swings, increased appetite, and complete AV block are not reported side effects.
The nurse on the antenatal unit is planning care for four clients. The nurse should assess which of the following clients first?
- A. A 29-year-old G3 P2 carrying twins, being treated for preterm labor at 29 weeks' gestation. She is receiving magnesium sulfate @ 2 g\hour. She has had no contractions for the past 2 hours and both twins appear stable, according to the nurse's shift report
- B. A 19-year-old 18 weeks' IUP who is now 12 hours post motor vehicle accident with bright red vaginal bleeding
- C. A G8 P4 Ab3 at 38 weeks' gestation hospitalized frequently during this pregnancy for placenta previa. Two days ago she was admitted with severe bright red vaginal bleeding that has tapered off now
- D. A 9-week IUP hospitalized for hyperemesis gravidarum who has not vomited for the last 12 hours
Correct Answer: B
Rationale: The 19-year-old with bright red vaginal bleeding post-accident at 18 weeks is at high risk for miscarriage or placental abruption, requiring immediate assessment. The other clients are stable or less acute.