Nokea
The nurse is assessing a client with a suspected perforated peptic ulcer. Which of the following findings is most indicative of this condition?
- A. Sudden severe abdominal pain.
- B. Chronic epigastric pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Sudden severe abdominal pain is a hallmark sign of a perforated peptic ulcer due to peritoneal irritation.
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A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Take two puffs twice daily.
Correct Answer: B
Rationale: Rinsing the mouth after using tiotropium prevents oral candidiasis, a common side effect of inhaled anticholinergics.
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
- A. Accepting the client while not arguing with the delusion.
- B. Focusing on the feelings or meaning of the delusion.
- C. Focusing on events and topics based in reality.
- D. Confronting the client's beliefs.
- E. Interacting with the client only when he is based in reality.
Correct Answer: A,B,C
Rationale: To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.
A client with a history of depression is prescribed duloxetine (Cymbalta). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Increased blood pressure.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Duloxetine can cause increased blood pressure, requiring immediate reporting to prevent cardiovascular complications.
A client has been taking lisinopril for 3 months. The client reports to the nurse a persistent dry cough that began about 1 month ago. The nurse interprets that the most likely reason for the client's complaint is what?
- A. Neutropenia as a result of therapy
- B. An expected side effect of therapy
- C. Undiagnosed existence of heart failure
- D. A concurrent upper respiratory infection
Correct Answer: B
Rationale: A frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, is the appearance of a persistent, dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the primary health care provider if the cough becomes very troublesome to them. The other options are incorrect interpretations.
Immediately after the client receives an injection of bupivacaine (Marcaine), he becomes restless and nervous and reports a feeling of impending doom. Which of the following actions by the nurse is appropriate at this time?
- A. Ask the client to talk more about what he is feeling
- B. Reassure the client that it is normal to feel restless before a procedure
- C. Assess the client's vital signs
- D. Administer epinephrine
Correct Answer: C
Rationale: Restlessness, nervousness, and a feeling of impending doom after bupivacaine injection may indicate systemic toxicity or an allergic reaction, requiring immediate vital sign assessment to guide further action. Talking, reassurance, or administering epinephrine without assessment is premature.