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The LPN has been asked to help a client taking Risperdal with activities of daily living in the morning. Which of these tasks is most likely to be potentially impacted by this medication?
- A. eating breakfast
- B. drinking fluids
- C. getting out of bed to use the bathroom
- D. brushing teeth
Correct Answer: C
Rationale: The correct answer is 'getting out of bed to use the bathroom.' Risperdal can cause orthostatic hypotension, leading to a drop in blood pressure when changing positions from lying down to standing up. This effect increases the risk of falls, emphasizing the need to assist the client with this task to prevent potential harm. Choices A, B, and D are less likely to be directly impacted by the medication, unlike the significant risk of orthostatic hypotension associated with changing positions.
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The LPN is preparing a client for discharge, and the discharge medications include phenobarbital. Which of these client statements would indicate a need for reinforced teaching about this medication?
- A. "I will need to avoid eating excessive leafy greens."?
- B. "It's best to take this medication with food."?
- C. "I can't wait to get back to my nightly glass of wine."?
- D. "I should try to take this medication at the same time every day."?
Correct Answer: C
Rationale: The correct answer is, "I can't wait to get back to my nightly glass of wine,"? as phenobarbital should not be taken with alcohol as it is a barbiturate. Alcohol may increase the sedative effect, posing risks to the patient's safety. Choice A, "I will need to avoid eating excessive leafy greens,"? is unrelated to phenobarbital and not a cause for reinforced teaching. Choice B, "It's best to take this medication with food,"? is a general instruction and not specific to phenobarbital. Choice D, "I should try to take this medication at the same time every day,"? is a common recommendation for medication adherence but does not highlight a specific concern related to phenobarbital.
The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?
- A. Make a referral for grief counseling.
- B. Allow the woman to see her baby initially and respect her wishes for further visits.
- C. Provide opportunities for the woman to express her feelings.
- D. Inform the woman she has the right to change her mind about relinquishment.
Correct Answer: C
Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.
When caring for pediatric clients, the nurse should pay special attention to the psychosocial development stages credited to whom?
- A. Robert Peck
- B. Erik Erikson
- C. Sigmund Freud
- D. Jean Piaget
Correct Answer: B
Rationale: Erik Erikson is credited with the psychosocial development theory and eight stages. The nurse should consider these stages when caring for pediatric clients to evaluate their development. Jean Piaget is known for cognitive development, Sigmund Freud for psychosexual development, and Robert Peck for aging theory. Therefore, the correct answer is Erik Erikson.
The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?
- A. I'm worried that my child is not using two-word phrases yet.
- B. My child has recently taken a few steps but does not seem stable when standing.
- C. My child seems to have developed separation anxiety when I leave.
- D. I'm letting my child use a spoon to eat.
Correct Answer: B
Rationale: The correct answer is 'My child has recently taken a few steps but does not seem stable when standing.' By 18 months of age, children should have taken their first steps and stand well. If a child hasn't made progress by this age, a physical therapy evaluation may be necessary. It is normal for an 18-month-old to start using a spoon to eat. However, the use of two-word phrases is not typically expected until 2 years of age. Separation anxiety is a common developmental phase that typically occurs between 6 and 18 months, so it does not require immediate follow-up. Therefore, the statement about the child not being stable when standing raises a red flag and necessitates further evaluation.
A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?
- A. Constriction of the underlying blood vessels
- B. An increased amount of bilirubin in the blood
- C. Increased perfusion of the surrounding tissues
- D. Excess blood in the dilated superficial capillaries
Correct Answer: D
Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.