Nokea
The nurse is caring for a client prescribed tizanidine. The nurse understands that this medication has had a therapeutic effect when the client reports
- A. Increased ability to focus
- B. Decreased muscle spasms
- C. Improved short-term memory
- D. Sleeping without awakening at night
Correct Answer: B
Rationale: Tizanidine is a muscle relaxant used to treat spasticity. A therapeutic effect is indicated by decreased muscle spasms. Increased focus, improved memory, and better sleep are not primary effects of tizanidine.
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The nurse has received a prescription for midazolam. Which of the following client findings requires follow-up with the physician prior to administering this medication?
- A. Cocaine intoxication
- B. Respiratory acidosis
- C. Tonic-clonic seizures
- D. Aggression
Correct Answer: B
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression, which is dangerous in clients with respiratory acidosis. Tonic-clonic seizures are an indication for midazolam, while cocaine intoxication and aggression are less directly contraindicated.
The nurse is assessing a client who is postoperative following a hypophysectomy. Which of the following findings should the nurse report to the primary healthcare provider (PHCP) immediately?
- A. Client reports a decreased smell
- B. No bowel movement in two days
- C. Foul-smelling breath
- D. Hourly urine output of 125 mL
Correct Answer: D
Rationale: High urine output suggests diabetes insipidus, a serious complication post-hypophysectomy.
The nurse has administered the first dose of prescribed rivastigmine to a client with Alzheimer's disease. Which clinical data is necessary to monitor while this client takes this medication?
- A. Glucose
- B. Weight
- C. Creatinine
- D. Hemoglobin and hematocrit
Correct Answer: B
Rationale: Rivastigmine, a cholinesterase inhibitor, can cause gastrointestinal side effects such as nausea, vomiting, and weight loss. Monitoring weight is essential to assess for significant weight loss, which can impact the client's health. Glucose, creatinine, and hemoglobin/hematocrit are not typically affected by rivastigmine.
The nurse is caring for a client with narcolepsy. The nurse anticipates which prescription from the primary healthcare provider?
- A. Trazodone
- B. Modafinil
- C. Diazepam
- D. Fluoxetine
Correct Answer: B
Rationale: Modafinil is a wakefulness-promoting agent used to treat excessive daytime sleepiness in narcolepsy. Trazodone, diazepam, and fluoxetine are not indicated for narcolepsy.
The nurse is caring for a client experiencing autonomic dysreflexia. What action should the nurse perform first?
- A. Administer sublingual nitroglycerin.
- B. Elevate the head of the bed.
- C. Obtain a residual volume reading with a bladder scan.
- D. Perform a digital examination to assess for the presence of stool.
Correct Answer: B
Rationale: Elevating the head of the bed reduces blood pressure in autonomic dysreflexia.