Nokea
The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?
- A. Inappropriate laughter.
- B. An exaggerated sense of well-being.
- C. Slurring of words when excited.
- D. Visual hallucinations.
Correct Answer: B
Rationale: Euphoria in multiple sclerosis is characterized by an exaggerated sense of well-being, often disproportionate to the client's condition.
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The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?
- A. Implementing relaxation exercises.
- B. Administering a sedative as needed.
- C. Administering prophylactic antacids or histamine-2 receptor antagonists.
- D. Monitoring the client's nutritional status closely.
Correct Answer: C
Rationale: Prophylactic antacids or H2 receptor antagonists reduce gastric acid, preventing stress ulcers in burn patients, who are at high risk due to stress response.
A client with a diagnosis of Cushing's syndrome is prescribed ketoconazole. The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Liver toxicity.
- C. Weight gain.
- D. Hypertension.
Correct Answer: B
Rationale: Ketoconazole can cause liver toxicity, requiring regular monitoring of liver function tests.
The nurse is instructing a Hindu client to increase protein in the diet. Which of the following foods are appropriate to include in this client's diet? Select all that apply.
- A. Lentil soup.
- B. Hamburger.
- C. 3 mm.
- D. Veal cutlet.
- E. Broiled fish sandwich.
Correct Answer: A
Rationale: Hindus typically follow a vegetarian diet, so lentil soup is appropriate, while meat-based options like hamburger, veal, and fish are not.
A client is hospitalized for ingesting an overdose of acetaminophen. The nurse prepares to administer which specific antidote for this medication overdose?
- A. Flumazenil
- B. Phytonadione
- C. N-acetylcysteine
- D. Naloxone hydrochloride
Correct Answer: C
Rationale: Acetylcysteine restores sulfhydryl groups that are depleted by acetaminophen metabolism. Flumazenil is the antidote for benzodiazepine reversal. Phytonadione is the antidote for warfarin sodium. Naloxone hydrochloride reverses respiratory depression caused by an opioid.
A client with acute myocardial infarction receives therapy with alteplase. Which finding indicates to the nurse that the client is experiencing a possible complication?
- A. Epistaxis
- B. Vomiting
- C. ECG changes
- D. Absent pedal pulses
Correct Answer: A
Rationale: Bleeding is an adverse effect of altepase therapy. The bleeding can be superficial or internal and can be spontaneous. None of the remaining options are side or adverse effects of altepase therapy.