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The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment findings would suggest the complication of autonomic dysreflexia?
- A. Urinary bladder spasm pain.
- B. Severe pounding headache.
- C. Tachycardia.
- D. Severe hypotension.
Correct Answer: B
Rationale: severe headache results from rapid onset of hypertension
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The nurse is teaching a client with a new diagnosis of chronic obstructive pulmonary disease (COPD) about tiotropium (Spiriva). Which of the following instructions should the nurse include?
- A. Use the inhaler as needed for shortness of breath.
- B. Report any eye pain or vision changes.
- C. Stop the medication if symptoms improve.
- D. Avoid rinsing the mouth after use.
Correct Answer: B
Rationale: Eye pain or vision changes may indicate glaucoma, a serious tiotropium side effect. Options A, C, and D are incorrect.
A woman calls the physician's office stating that her 16-year-old daughter took 20 or 30 sleeping pills. The mother tells the nurse that her daughter is awake and says, 'Leave me alone. I just want to die.' How should the nurse respond?
- A. Ask her why she wants to die.'
- B. Try to convince her that she wants to live.'
- C. Give her a glass of milk to bind the medication.'
- D. Call 911 and get her to the closest emergency room immediately.'
Correct Answer: D
Rationale: A suicide attempt with sleeping pills requires immediate emergency care to prevent overdose complications. Other responses delay critical intervention.
A client receiving cromolyn sodium (Intal).
Which of the following statements, if made by the client to the nurse, indicates that teaching has been successful?
- A. I will take the medicine with my meals.
- B. It is important that I take the medication before going to bed.
- C. If I experience respiratory distress, I will take the medicine.
- D. I will take the medicine before I begin any vigorous exercise.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate information (2) inappropriate information (3) cromolyn sodium is not an antihistamine agent, an antiinflammatory, or a bronchodilator, does nothing for a client in respiratory distress (4) correct-cromolyn sodium (Intal) is used to prevent the release of histamine and other allergy-triggering substances
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropesol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
- A. Raise the side rails on the bed
- B. Place the call bell within reach
- C. Instruct the client to remain in bed
- D. Have the client empty bladder
Correct Answer: D
Rationale: Have the client empty bladder. The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D, C, B, A. Note: It is much easier to administer IM meds with the side rails down, and then raising them when the nurse is done. Other activities can then be carried out more safely.
The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated
- A. I can only wear cotton socks.'
- B. I cannot go barefoot around my house.'
- C. I will trim corns and calluses regularly.'
- D. I should ask a family member to inspect my feet daily.'
Correct Answer: C
Rationale: I will trim corns and calluses regularly.' Clients who are elderly, have diabetes, and/or have vascular disease often have decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks which have not been mended, and always wear shoes when out of bed. They should not cut their nails, corns, and calluses, but should have them trimmed by their provider, nurse, or another provider who specializes in foot care.