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The nurse is assessing the client newly started on benztropine mesylate. Which findings indicate that the client is experiencing the most common side effects of benztropine mesylate?
- A. Dizziness, headache, and insomnia
- B. Weight gain, tremors, and sedation
- C. Blurred vision, dry mouth, and constipation
- D. Headache, dry mouth, and sexual dysfunction
Correct Answer: C
Rationale: Blurred vision, dry mouth, and constipation are common side effects of anticholinergic agents like benztropine mesylate (Cogentin).
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The nurse is caring for the client taking atorvastatin. The nurse should assess for which adverse effects?
- A. Constipation and hemorrhoids
- B. Muscle pain and weakness
- C. Fatigue and dysrhythmias
- D. Flushing and postural hypotension
Correct Answer: B
Rationale: A: Bile acid sequestrants act by inhibiting bile acids from absorption by the small intestine. This results in fewer bile acids in the small intestine, which may lead to constipation and hemorrhoids. B: Atorvastatin (Lipitor) is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor (statin) used to lower lipid levels. Statins can cause muscle tissue injury manifested by muscle ache or weakness. Muscle injury can progress to myositis (muscle inflammation) or rhabdomyolysis (muscle disintegration). C: Diarrhea, not constipation, has been found to be a side effect of statin medications. D: Side effects of niacin, a lipid-lowering agent, include flushing, dysrhythmias, and postural hypotension.
Methylphenidate hydrochloride is prescribed for the child with ADHD. The nurse should teach the parents to administer the medication in which way?
- A. Whenever the child exhibits inattention behaviors
- B. Whenever the child exhibits hyperactive behaviors
- C. With a snack before bed to calm the child for sleep
- D. During or after meals if the medication decreases appetite
Correct Answer: D
Rationale: A: Methylphenidate is usually given twice daily at or before breakfast and at noon, not whenever inattention behaviors occur. B: Methylphenidate is usually given twice daily at or before breakfast and at noon, not whenever hyperactive behaviors occur. C: The last dose of the medication should be given before 6 p.m. to prevent insomnia. D: A side effect of methylphenidate hydrochloride (Ritalin) is anorexia. It should be given during or immediately after breakfast and lunch to prevent a decreased intake.
The LPN is performing an assessment on a 4-day-old 8-pound, 6-ounce newborn with a head circumference of 33 cm. Given this information, what would the nurse expect the child's chest circumference to be?
- A. about 31 cm
- B. about 36 cm
- C. about 29 cm
- D. about 33 cm
Correct Answer: A
Rationale: In newborns, the head circumference should be 2 cm to 3 cm larger than the chest circumference. Note: Due to molding that occurs during the birth process, the head and chest measurement may be nearly equal during the first 48 hours after birth.
Which of the following would likely not be a barrier to learning?
- A. a client who took Ambien an hour ago
- B. a bipolar client currently in a manic phase
- C. a client who states they are not interested
- D. a client with dysphagia
Correct Answer: D
Rationale: Dysphagia may be a barrier to communication but not to learning. Barriers to learning include an altered mental status, taking sedative medications, and lack of motivation to learn.
The child with CF is receiving albuterol. Which response should the nurse expect if albuterol is achieving the desired therapeutic effect?
- A. Increased heart rate
- B. Improved weight gain
- C. Fewer hospitalizations
- D. Fewer adventitious lung sounds
Correct Answer: D
Rationale: A: Albuterol may increase HR, but this is not the desired therapeutic effect. B: Weight should not be affected by albuterol. C: The use of a bronchodilator has not been demonstrated to decrease hospitalization frequency. D: The desired therapeutic effect of a bronchodilator such as albuterol (Proventil) is a reduction in adventitious (abnormal) breath sounds.