Nokea
The nurse is assigned to care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving amphotericin B for a fungal respiratory infection. Which would indicate an adverse effect of the medication?
- A. Hypokalemia
- B. Hypernatremia
- C. Hypochloremia
- D. Hypercalcemia
Correct Answer: A
Rationale: Clients receiving amphotericin B may develop hypokalemia, which can be severe and lead to extreme muscle weakness and electrocardiogram changes. Distal renal tubular acidosis commonly occurs, and this contributes to the development of hypokalemia. High potassium levels do not occur. The medication does not cause sodium, chloride, or calcium levels to fluctuate.
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The nurse caring for a client with Graves' disease is concerned about the client's calorie intake because of the resulting hypercatabolic state of the disorder. Which situation indicates a successful outcome for this concern?
- A. The client verbalizes the need to avoid snacking between meals.
- B. The client discusses the relationship between mealtime and the blood glucose level.
- C. The client maintains a normal weight or gradually gains weight if it is below normal.
- D. The client demonstrates knowledge regarding the need to consume a diet that is high in fat and low in protein.
Correct Answer: C
Rationale: Graves' disease causes a state of chronic nutritional and caloric deficiency caused by the metabolic effects of excessive T3 and T4. Clinical manifestations are weight loss and increased appetite. Therefore, it is a nutritional goal that the client will not lose additional weight and he or she will gradually return to the ideal body weight, if necessary. To accomplish this, the client must be encouraged to eat frequent high-calorie, high-protein, and high-carbohydrate meals and snacks.
A client regularly takes nonsteroidal antiinflammatory drugs (NSAIDs) and misoprostol has been added to the medication regimen. The nurse should monitor the client for the relief of which sign/symptom?
- A. Diarrhea
- B. Bleeding
- C. Infection
- D. Epigastric pain
Correct Answer: D
Rationale: The client who regularly takes NSAIDs is prone to gastric mucosal injury, which gives the client epigastric pain as a symptom. Misoprostol is administered to prevent this occurrence. Diarrhea can be a side effect of the medication, but its relief is not an intended effect. Bleeding and infection are unrelated to the question.
A client has just taken a dose of trimethobenzamide. When the client states relief of which sign/symptom, is it appropriate for the nurse to determine that the medication has been effective?
- A. Nausea
- B. Heartburn
- C. Constipation
- D. Abdominal pain
Correct Answer: A
Rationale: Trimethobenzamide is an antiemetic agent that is used for the treatment of nausea and vomiting. The medication is not used to treat heartburn, constipation, or abdominal pain.
An older client is a victim of elder abuse. He and his family have been attending counseling sessions for the past month. Which statement, made by the abusive family member, would indicate an understanding of more positive coping skills?
- A. I will be more careful to make sure that my father's needs are 100 \% met.
- B. I am so sorry and embarrassed that the abusive event occurred. It won't happen again.
- C. I feel better equipped to care for my father now that I know where to turn if I need assistance.
- D. Now that my father is going to move into my home with me, I will have to stop drinking alcohol.
Correct Answer: C
Rationale: Elder abuse is sometimes caused by family members who are being expected to care for their aging parents. This care can cause the family to become overextended, frustrated, or financially depleted. Knowing where to turn in the community for assistance with caring for an aging family member can bring much-needed relief. Using these alternatives is a positive coping skill for many families. The rest of the options are statements of good faith or promises, which may or may not be kept in the future.
A client is prescribed glipizide once daily. What intended effect of this medication should the nurse observe for?
- A. Weight loss
- B. Resolution of infection
- C. Decreased blood glucose
- D. Decreased blood pressure
Correct Answer: C
Rationale: Glipizide is an oral hypoglycemic agent that is taken in the morning. It is not used to enhance weight loss, treat infection, or decrease blood pressure.