Nokea
The nurse is assessing a client with suspected dehydration. Which of the following findings would the nurse expect?
- A. Bradycardia and hypertension.
- B. Dry mucous membranes and tented skin.
- C. Clear, dilute urine.
- D. Increased respiratory rate.
Correct Answer: B
Rationale: dry mucous membranes and tented skin are signs of dehydration due to fluid loss
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The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?
- A. Diabetes
- B. Prinzmetal's angina
- C. Cancer
- D. Cluster headaches
Correct Answer: B
Rationale: Prinzmetal's angina is a contraindication for sumatriptan due to the risk of coronary vasospasm, and this should be reported to the doctor.
The following clients are to be assigned for daily care. The newly licensed nurse should not be assigned to provide primary care for the client with:
- A. Full-thickness burns of the abdomen and upper thighs
- B. A fractured hip scheduled for hip replacement
- C. Ileal reservoir following a cystectomy
- D. Noncardiogenic pulmonary edema (ARDS)
Correct Answer: D
Rationale: ARDS requires complex respiratory management, which is beyond the scope of a newly licensed nurse.
The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?
- A. Pain at the site
- B. Warm fingers
- C. Pulses rapid
- D. Paresthesia of the fingers
Correct Answer: D
Rationale: Paresthesia of the fingers suggests possible nerve compression or compartment syndrome, which requires immediate reporting to the doctor.
The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:
- A. Optimal restoration of the client's elimination pattern
- B. Restoration of the client's neurosensory function
- C. Prevention of complications from impaired elimination
- D. Promotion of a positive body image
Correct Answer: C
Rationale: The primary goal is to prevent complications like infections or skin breakdown by establishing effective bowel and bladder management.
A client with psychotic depression is receiving haloperidol (Haldol). Which of the following adverse effects is associated with haloperidol?
- A. Akathisia
- B. Cataracts
- C. Diaphoresis
- D. Polyuria
Correct Answer: A
Rationale: Akathisia, a movement disorder characterized by restlessness, is a common extrapyramidal side effect of haloperidol.