Nokea
The nurse is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?
- A. I am nervous about how painful labor will be.
- B. I need to review my finances and make sure I am prepared to care for a child.
- C. I hate this nausea that I've been having for a week.
- D. I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent.
Correct Answer: D
Rationale: The nurse should follow up on the client's lack of support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea.
You may also like to solve these questions
New medications are prescribed for the client taking lithium. Which medication, if prescribed, should the nurse question with the HCP?
- A. Isosorbide dinitrate by mouth tid
- B. Prednisone 20 mg by mouth daily
- C. Furosemide 80 mg by mouth daily
- D. Insulin aspart 2 units subcut with meals
Correct Answer: C
Rationale: Furosemide (Lasix) is a loop diuretic that promotes sodium loss and lithium retention, increasing serum lithium levels and risk of toxicity.
The client with schizophrenia has a history of nonadherence to the prescribed medication regimen. Injectable antipsychotic agents are being considered for long-term use. Which medications, if prescribed by the HCP, should the nurse question? Select all that apply.
- A. Olanzapine
- B. Ziprasidone
- C. Aripiprazole
- D. Risperidone Consta
- E. Fluphenazine decanoate
Correct Answer: A,B,C
Rationale: Olanzapine and ziprasidone injections are for short-term use, and aripiprazole is not available in injectable form.
The nurse applies a fentanyl transdermal patch to the client for the first time. Shortly after application, the client is experiencing pain. Which nursing action is most appropriate?
- A. Remove the transdermal patch and apply a new one.
- B. Administer a short-acting opioid analgesic medication.
- C. Rub the transdermal patch to enhance drug absorption.
- D. Call the HCP to request a higher-dosed fentanyl patch.
Correct Answer: B
Rationale: A: Removing the patch is unnecessary; effective analgesia may take 12 to 24 hours. B: The nurse should administer a short-acting opioid analgesic. When the first fentanyl (Duragesic) transdermal patch is applied, effective analgesia may take 12 to 24 hours because absorption is slow. C: Transdermal patches should not be rubbed to enhance absorption; it can cause the delivery of the medication to fluctuate. D: It is premature to request a higher dose of fentanyl.
The nurse is leading a group session for clients with panic disorder. Which statement made by the client indicates that further teaching is needed?
- A. I need to be able to identify triggers that escalate my anxiety to the point of panic.
- B. Diazepam is the long-term medication of choice because of its nonaddicting quality.
- C. Citalopram has been found to be helpful in the long-term treatment of panic disorder.
- D. I can use guided imagery and meditation to effectively reduce my anxiety symptoms.
Correct Answer: B
Rationale: Buspirone, not diazepam (Valium), is the long-term medication of choice for panic disorder due to its nonaddicting quality.
The nurse is preparing to care for the 14-month-old newly hospitalized toddler with bacterial gastroenteritis and severe dehydration. Which initial collaborative interventions should the nurse expect to implement? Select all that apply.
- A. IV antibiotic to treat infection
- B. Oral fluids for fluid rehydration
- C. IV fluid therapy for rehydration
- D. Analgesics for pain and discomfort
- E. An antidiarrheal to control diarrhea
- F. Antipyretic for elevated temperature
Correct Answer: A,C,F
Rationale: A: Antibiotics may be prescribed to treat bacterial gastroenteritis to ensure complete recovery. B: Oral fluid rehydration will be initiated later, but not initially, when the toddler presents with severe dehydration. C: The child who presents with severe dehydration needs IV therapy to stabilize the balance of fluids and electrolytes. D: The pain and discomfort the toddler will have are due to fever and cramping from the GI illness; thus, analgesics are usually not prescribed. E: An antidiarrheal medication is contraindicated. F: Fever is often a symptom of gastroenteritis. Ensuring that the fever is controlled will provide some comfort.