Nokea
The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?
- A. Monitor for hyperkalemia
- B. Place in protective isolation
- C. Precautions with position changes
- D. Administer diuretics as ordered
Correct Answer: C
Rationale: Precautions with position changes. Multiple myeloma causes osteoporosis, increasing the risk of pathological fractures, necessitating careful positioning.
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A client with bipolar disorder receives Eskalith (lithium carbonate) bid. Which observation is associated with lithium toxicity?
- A. Hyporeflexia
- B. Akathesia
- C. Ataxia
- D. Petechiae
Correct Answer: C
Rationale: Ataxia , or impaired coordination, is a sign of lithium toxicity. Hyporeflexia is not typical. Akathesia is restlessness, often linked to antipsychotics. Petechiae indicate bleeding issues, not lithium toxicity.
A 10-year-old for a cardiac catheterization.
Which of the following plans would be MOST appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization?
- A. Show a videotape specifically prepared for children about cardiac catheterization.
- B. Provide the child with a pamphlet about the procedure and encourage him to read it.
- C. Draw a picture of a heart and explain where the tube will go and what the doctor will see.
- D. Present a puppet show explaining the anatomy and physiology of the heart.
Correct Answer: C
Rationale: Strategy: Think about the developmental stage of a 10-year-old. (1) video will provide correct information but is not best preparation for a school-age child (2) pamphlet will contain correct information but is not best preparation for a school-age child (3) correct-this plan will best prepare the child for the procedure (4) would be more appropriate for a younger child
The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired all the time.
- B. I have trouble sleeping at night.
- C. I think about hurting myself sometimes.
- D. I have a dry mouth.
Correct Answer: C
Rationale: Thoughts of self-harm indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on sertraline. Options A, B, and D are common side effects of SSRIs (fatigue, insomnia, dry mouth) and less urgent.
The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's
- A. poor nutritional status
- B. decreased gastrointestinal motility
- C. increased splanchnic blood flow
- D. altered peripheral resistance
Correct Answer: B
Rationale: Decreased gastrointestinal motility, together with shrinkage of the gastric mucosa and changes in hydrochloric acid levels, will decrease absorption of medications and interfere with their actions.
A young child with a history of grand mal seizures is in public school. He is on phenobarbital and hydantoin (Dilantin) to control the seizures. His teacher tells the nurse that he has not had any seizures but he does keep falling asleep in class. What should the nurse include when discussing his drowsiness with the teacher?
- A. It is common in children who take barbiturates.
- B. It usually occurs after seizures; let him sleep.
- C. It is probably not related to his seizure disorder or treatment.
- D. It is probably a warning sign that he is about to have a seizure.
Correct Answer: A
Rationale: Phenobarbital, a barbiturate, commonly causes drowsiness, explaining the child's sleepiness in class, which should be monitored but is expected.