Nokea
The nurse is caring for a client who ingested a lethal dose of aspirin (ASA). Which assessment finding is most concerning?
- A. Pulmonary edema
- B. Tinnitus
- C. Nausea and vomiting
- D. Tachycardia
Correct Answer: A
Rationale: Pulmonary edema is life-threatening and indicates severe aspirin toxicity, potentially leading to respiratory failure.
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Although all of the following measures might be useful in reducing the visual disability of a client with adult macular degeneration (AMD), which measure should the nurse teach the client primarily as a safety precaution?
- A. Wear a patch over one eye.
- B. Place personal items on the sighted side.
- C. Lie in bed with the unaffected side toward the door.
- D. Turn the head from side to side when walking.
Correct Answer: B
Rationale: Placing personal items on the sighted side enhances safety by ensuring the client can see and access items easily, reducing the risk of falls or accidents.
The nurse is teaching a group of teenage boys who are on a baseball team about the risks of chewing tobacco. Which of the following should the nurse instruct the teenagers to report to their parents and physicians? Select all that apply.
- A. Dysphagia.
- B. Sessibility in the
- C. Unexplained mouth pain.
- D. Lump in the neck.
- E. Decreased saliva.
- F. White patch on the mucosa.
Correct Answer: C,D,F
Rationale: Chewing tobacco is a known risk factor for oral cancer and other oral health issues. Symptoms such as unexplained mouth pain, a lump in the neck, and white patches on the mucosa are concerning and could indicate serious conditions like oral cancer or precancerous lesions, requiring immediate medical attention. Dysphagia and decreased saliva are less specific and not directly linked to chewing tobacco risks in this context.
A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/minute and shallow. The nurse interprets these findings as indicating which of the following?
- A. Expected common adverse effects.
- B. Hypersensitivity reaction.
- C. Possible habituating effect.
- D. Hemorrhage from gastrointestinal irritation.
Correct Answer: B
Rationale: These vital signs suggest a hypersensitivity reaction, a serious adverse effect of carisoprodol.
Which of the following is contraindicated for a client with seizure precautions?
- A. Encouraging him to perform his own personal hygiene.
- B. Allowing him to wear his own clothing.
- C. Assessing oral temperature with a glass thermometer.
- D. Encouraging him to be out of bed.
Correct Answer: C
Rationale: Using a glass thermometer is contraindicated due to the risk of breakage and injury during a seizure. Personal hygiene, wearing own clothing, and being out of bed are safe and promote independence.
A 74-year-old female is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a permanent pacemaker is to:
- A. Maintain skin integrity.
- B. Maintain cardiac conduction stability.
- C. Decrease cardiac output.
- D. Increase activity level.
Correct Answer: B
Rationale: Maintaining cardiac conduction stability is the priority post-pacemaker insertion to ensure the device effectively manages bradycardia.