Nokea
The nurse counsels a 70-year-old woman who comes to the outpatient clinic for a routine examination.
- A. What should the nurse suspect in a 70-year-old woman taking laxatives twice daily and a suppository once daily?
- B. Has an anal fixation resulting from recent loss of her husband.
- C. Is depressed due to alterations in inTest inal absorption and excretion.
- D. Is experiencing excessive concern with body function due to physical changes.
- E. Has regressed due to a fear of losing the ability to have bowel movements.
Correct Answer: C
Rationale: Excessive laxative use in a 70-year-old likely reflects overconcern with bowel function, common in elderly patients facing physical changes like constipation. There’s no evidence of anal fixation, depression, or regression in the scenario.
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The nurse is caring for a client who is receiving IV ceftriaxone for a urinary tract infection. Which of the following findings would be of GREATest concern to the nurse?
- A. White blood cell count of 12,000/mm^3.
- B. Temperature of 100.4°F (38°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.4°F suggests worsening infection or inadequate antibiotic coverage, requiring immediate evaluation. Options A, C, and D are less concerning: WBC 12,000/mm^3 is expected, urine output 50 mL/hour is normal, and blood pressure 120/80 mmHg is stable.
The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following instructions should the nurse include?
- A. Take the medication daily to prevent migraines.
- B. Report any chest pain.
- C. Stop the medication if headaches decrease.
- D. Avoid regular neurological exams.
Correct Answer: B
Rationale: Chest pain may indicate vasoconstriction, a serious sumatriptan side effect. Options A, C, and D are incorrect.
A pregnant diabetic client, who is 37 weeks gestation, is scheduled for an amniocentesis. The client asks the nurse the purpose of the test. The nurse should explain that the primary reason for performing an amniocentesis is:
- A. To determine the effect of the diabetes on the fetus
- B. To estimate the skeletal age of the fetus
- C. To determine the fetal lung maturity
- D. To obtain information about aberrant fetal genes
Correct Answer: C
Rationale: At 37 weeks, amniocentesis primarily assesses fetal lung maturity via lecithin/sphingomyelin ratio, critical for delivery planning. Diabetes effects , skeletal age , and genetic issues are less common indications.
The nurse is preparing a five-year-old child for surgery.
- A. What is the best action for the nurse when the informed consent for a five-year-old’s surgery is signed by the mother, and the parents are divorced with joint legal custody?
- B. Notify the physician.
- C. Inform surgery.
- D. Contact the father to obtain consent.
- E. Continue the child’s preoperative preparation.
Correct Answer: D
Rationale: In cases of joint legal custody, consent from either parent is sufficient for surgical procedures. Since the mother has signed the informed consent, no further action is needed, and the nurse should continue preoperative preparation. Notifying the physician, informing surgery, or contacting the father is unnecessary.
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Creatinine 2.5 mg/dL.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A creatinine of 2.5 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.