Nokea
The mother of a 28-year-old client who is taking clozapine [Clozaril] states, 'Something is wrong. My son is drooling like a baby.' Which of the following responses by the nurse would be most helpful?
- A. I wonder if he's having an adverse reaction to the medicine.'
- B. Excess saliva is common with this drug; here's a paper cup for him to spit into.'
- C. Don't worry about it; this is only a minor inconvenience compared to its benefits.'
- D. I've seen this happen to other clients who are taking Clozaril.'
Correct Answer: B
Rationale: Excess salivation is a common side effect of clozapine. Providing a practical solution like a cup supports the client's comfort and addresses the mother's concern.
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A client with a history of hypothyroidism is prescribed levothyroxine (Synthroid). The nurse should instruct the client to:
- A. Take the medication at bedtime.
- B. Avoid taking the medication with grapefruit juice.
- C. Take the medication with a high-fiber meal.
- D. Stop the medication if palpitations occur.
Correct Answer: B
Rationale: Grapefruit juice can interfere with levothyroxine absorption, so it should be avoided.
The nurse is administering propranolol (Inderal) to a client for control of migraine headaches. The client's pulse rate is 56 bpm. What should the nurse do next?
- A. Contact the physician immediately.
- B. Assess blood pressure.
- C. Administer oxygen.
- D. Ask for a relative to contact.
Correct Answer: A
Rationale: Propranolol, a beta-blocker, can cause bradycardia. A pulse of 56 bpm is concerning and warrants immediate physician notification to evaluate the need for dose adjustment or intervention.
The nurse is planning to assist the physician with a thoracentesis for a client who has a pleural effusion. Which of the following positions would be appropriate for the client to assume?
- A. Lying supine with the arms extended.
- B. Lying prone with the head supported by the arms.
- C. Sitting upright and leaning on an overbed table.
- D. Side-lying with the knees drawn up to the abdomen.
Correct Answer: C
Rationale: Sitting upright and leaning on an overbed table facilitates access to the pleural space and ensures client comfort during thoracentesis.
The nurse assesses the assigned clients for the shift. Of the following assigned clients, which client is at greatest risk for falling?
- A. A 22-year-old man with three fractured ribs and a fractured left arm.
- B. A 70-year-old woman with episodes of syncope.
- C. A 50-year-old man with angina.
- D. A 30-year-old woman with a fractured ankle.
Correct Answer: B
Rationale: Syncope increases fall risk due to sudden loss of consciousness, particularly in an elderly client with potential comorbidities.
A 16-year-old client is in the emergency department for treatment of minor injuries from a car accident. A crisis nurse is with her because she became hysterical and was saying, 'It's my fault. My Mom is going to kill me. I don't even have a way home.' Which of the following should be the nurse's initial intervention?
- A. Hold her hands and say, 'Slow down. Take a deep breath.'
- B. Say, 'Calm down. The police can take you home.'
- C. Put a hand on her shoulder and say, 'It wasn't your fault.'
- D. Say, 'Your mother is not going to kill you. Stop worrying.'
Correct Answer: A
Rationale: This intervention calms the client's hysteria using physical touch and breathing techniques, helping her regain composure before addressing other concerns.