Nokea
The nurse is assessing a client who is postoperative following a hypophysectomy. Which of the following findings should the nurse report to the primary healthcare provider (PHCP) immediately?
- A. Client reports a decreased smell
- B. No bowel movement in two days
- C. Foul-smelling breath
- D. Hourly urine output of 125 mL
Correct Answer: D
Rationale: High urine output suggests diabetes insipidus, a serious complication post-hypophysectomy.
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The nurse is assessing a client receiving prescribed donepezil. Throughout the duration of therapy, the nurse should monitor the client's
- A. Pulse
- B. Fasting blood glucose
- C. Total cholesterol
- D. Pulse oximetry
Correct Answer: A
Rationale: Donepezil, a cholinesterase inhibitor for Alzheimer's, can cause bradycardia due to increased vagal tone. Monitoring pulse is essential. Blood glucose, cholesterol, and pulse oximetry are not typically affected.
The nurse is performing medication reconciliation for a client with Parkinson's disease. Which medication should the nurse question with the primary healthcare provider (PHCP)?
- A. Haloperidol
- B. Levodopa-carbidopa
- C. Pramipexole
- D. Ropinirole
Correct Answer: A
Rationale: Haloperidol is a typical antipsychotic that blocks dopamine receptors, which can worsen Parkinson's disease symptoms by counteracting the dopamine-enhancing effects of medications like levodopa-carbidopa, pramipexole, and ropinirole, which are used to manage Parkinson's disease.
A nurse is caring for a client on bed rest following a spinal cord injury. When positioning the client's feet, which position would prevent the client from developing foot drop?
- A. Supination
- B. Dorsiflexion
- C. Hyperextension
- D. Abduction
Correct Answer: B
Rationale: Dorsiflexion prevents foot drop by maintaining proper foot alignment.
The nurse is caring for a client prescribed tizanidine. The nurse understands that this medication has had a therapeutic effect when the client reports
- A. Increased ability to focus
- B. Decreased muscle spasms
- C. Improved short-term memory
- D. Sleeping without awakening at night
Correct Answer: B
Rationale: Tizanidine is a muscle relaxant used to treat spasticity. A therapeutic effect is indicated by decreased muscle spasms. Increased focus, improved memory, and better sleep are not primary effects of tizanidine.
The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client's VPA level is 40 mcg/mL (50-125 mcg/mL). Based on the laboratory data, the nurse should
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for VPA toxicity
- D. Document the result as within normal limits
Correct Answer: A
Rationale: A VPA level of 40 mcg/mL is below the therapeutic range (50-125 mcg/mL), suggesting possible non-adherence to the prescribed regimen. Skipping a dose is inappropriate, toxicity is unlikely with a low level, and the result is not within normal limits.