Nokea
The nurse is assessing a client with suspected appendicitis. Which of the following findings would support this diagnosis?
- A. Pain at McBurney's point.
- B. Decreased bowel sounds.
- C. Bradycardia.
- D. Fever of 99°F.
Correct Answer: A, B
Rationale: Pain at McBurney's point and decreased bowel sounds are classic signs of appendicitis due to peritoneal irritation and intestinal obstruction.
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A client with a history of epilepsy is admitted with status epilepticus. The nurse should prioritize which of the following interventions?
- A. Administer lorazepam intravenously.
- B. Apply oxygen via nasal cannula.
- C. Insert a nasogastric tube.
- D. Position the client supine.
Correct Answer: A
Rationale: Lorazepam is the priority to stop seizures in status epilepticus.
A client has been prescribed metoclopramide on a long-term basis. A home care nurse calls the primary health care provider immediately if which side effect is noted in this client?
- A. Excitability
- B. Anxiety or irritability
- C. Uncontrolled rhythmic movements of the face or limbs
- D. Dry mouth not minimized by the use of sugar-free hard candy
Correct Answer: C
Rationale: Metoclopramide is a 'prokinetic' drug used to treat heartburn. If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should withhold the medication and call the primary health care provider. These side effects may be irreversible. Excitability is not a side effect of this medication. Anxiety, irritability, and dry mouth are milder side effects that are not harmful to the client.
Based on the fact that you family unit client is experiencing a situational crisis that has led to dysfunctional communication within the family unit, you have recommended that the entire nuclear family and members of the extended family who live in the family's home begin family therapy. The grandparents tell you that it is their grandson, rather than their son, who is addicted to prescription painkillers, is the cause of the problem; therefore, they do not have to participate in this group therapy. How should you respond to these grandparents?
- A. You should try to come to a few sessions at least because they may be very informative to you'.
- B. You are probably correct. This really is not your problem'.
- C. Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of the family including grandparents who live in the home.'
- D. You should attend because the doctor has ordered family therapy for you as extended family members'.
Correct Answer: C
Rationale: Addiction affects the entire family system, including extended family members living in the home. Their participation in therapy can help address dysfunctional communication and support the family unit as a whole.
The staff nurse is reviewing how to manage the last 2 hours of the night shift on an antepartal unit and has the following orders and tasks to complete prior to 7 a.m. The nurse should complete the tasks in which order?
- A. Check documentation, final check of each client.
- B. Fetal monitor strip for 1/2 hour q shift.
- C. Magnesium sulfate drawn at 6 a.m.
- D. Accucheck and sliding scale insulin due at 7, 11, 4, and hs.
Correct Answer: D,G,F,A
Rationale: To manage time effectively: Check documentation and final client checks at 6:30 to ensure all records are complete (A); perform the fetal monitor strip from 6:00 to 6:30 to meet the half-hour requirement (F); draw magnesium sulfate at 6:00 to align with the ordered time (G); perform Accucheck and insulin at 7:00 as per the schedule (D).
When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?
- A. I need to stay out of the sunlight for 3 days.
- B. The injection site may itch, but I can scratch it if I need to.
- C. I need to avoid sexual intercourse for 2 to 3 days after the vaccination.
- D. I need to prevent becoming pregnant for 2 to 3 months after the vaccination.
Correct Answer: D
Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.