Nokea
The newly hospitalized client admits using heroin 8 hours ago. Which assessment findings, if observed in the client, should the nurse associate with heroin withdrawal?
- A. Mental confusion, drowsiness, and hypotension
- B. Dysphoric mood, pupillary dilation, and sweating
- C. Pinpoint pupils, constipation, and urinary retention
- D. No withdrawal signs until 2 to 3 days have passed
Correct Answer: B
Rationale: Dysphoric mood, pupillary dilation, and sweating are signs of heroin withdrawal. Heroin is an opioid.
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The client diagnosed with BPD is taking Olanzapine. The nurse evaluates that Olanzapine is effective when observing a reduction in which behaviors? Select all that apply.
- A. Levels of anxiety
- B. The use of splitting
- C. Thoughts of paranoia
- D. Feelings of depression
- E. Expression of hostility
Correct Answer: A,C,E
Rationale: With BPD, reductions in anxiety, paranoia, and hostility indicate olanzapine (Zyprexa) is effective.
The nurse is assessing the child's ear with an otoscope prior to administering medications to treat persistent otitis media. Which assessment finding should the nurse expect?
- A. otoscope_1.PNG
- B. otoscope_2.PNG
- C. otoscope_3.PNG
- D. otoscope_4.PNG
Correct Answer: A
Rationale: A: This shows otitis media characterized by a bulging contour to the tympanic membrane, unclear ossicular landmarks, and yellowish middle ear effusion. B: This shows a perforated tympanic membrane, not otitis media. C: This shows a normal left ear tympanic membrane. The ossicular landmarks can be identified through the tympanic membrane. The nurse would not expect to see a normal tympanic membrane when the child has persistent otitis media. D: This shows the presence of a foreign body in the ear canal.
The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?
- A. The client has a history of Type II diabetes.
- B. The client is on a continuous tube-feeding regimen.
- C. The client is on fluid-restriction.
- D. The pharmacy has provided phenytoin in tablet form.
Correct Answer: B
Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status.
The client taking sertraline for treatment of depression for the past 11 months reports feeling much better and wishes to discontinue the medication. Which is the nurse's most appropriate response?
- A. The medication will have to be reduced gradually to prevent undesirable symptoms.
- B. You should not stop the medication without talking to your health care provider first.
- C. It appears that the medication has worked very well. It should be safe to discontinue its use.
- D. You should take this medication indefinitely to prevent recurrence of depressive symptoms.
Correct Answer: A
Rationale: Sertraline (Zoloft) is an SSRI antidepressant. Stopping these abruptly can cause withdrawal symptoms. The dose should be reduced gradually.
The nurse is preparing to administer IV fluids to the 13-kg child who has dehydration. The daily IV fluid requirement is to administer 1000 mL / 50 mL/kg over 10 kg. How many milliliters per hour should the nurse calculate to administer the IV therapy correctly?
Correct Answer: 48
Rationale: This child weighs 13 kg; the daily requirement is 1000 mL + (50 mL x 3) = 1150 mL/24 hr. The hourly rate is 1150 mL/ 24 hr = 47.9167 mL/hr, rounded to 48 mL/hr.