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The nurse is caring for a client with a diagnosis of Parkinson's disease who is taking benztropine mesylate daily. When assessing the client, what should the nurse specifically monitor for to determine if the client is experiencing a side effect of this medication?
- A. Pupil response
- B. Prothrombin time
- C. Skin temperature
- D. Intake and output
Correct Answer: D
Rationale: Urinary retention is a side effect of benztropine mesylate, an anticholinergic medication. The nurse needs to observe for dysuria, distended abdomen, voiding in small amounts, and overflow incontinence. The remaining options do not relate to this medication.
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The 2nd priority needs according to the MAAUAR method of priority setting include which of the following?
- A. Assessment
- B. Movement
- C. Understanding level
- D. Risks
Correct Answer: D
Rationale: The MAAUAR method prioritizes: Mental status, Acute pain, Acute eliminated needs, Urgent needs, Abnormal vital signs, Risks. The second priority is Acute pain, but among the options, Risks aligns as a high-priority need following initial physiological concerns.
The nurse is teaching a client with a new diagnosis of celiac disease about dietary management. Which of the following foods should the client avoid?
- A. Rice.
- B. Wheat.
- C. Corn.
- D. Potatoes.
Correct Answer: B
Rationale: Wheat contains gluten, which must be avoided in celiac disease.
The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include:
- A. Kussmaul's respirations
- B. Excessive hunger
- C. Dry, flaky skin
- D. High blood pressure
Correct Answer: A
Rationale: Kussmaul's respirations (rapid, deep breathing) are a hallmark of diabetic ketoacidosis as the body compensates for acidosis. Excessive hunger is more typical of hypoglycemia, and dry skin or hypertension are less specific.
The nurse is caring for a client with a history of glaucoma who is prescribed timolol (Timoptic) eye drops. The nurse should instruct the client to report which of the following side effects?
- A. Blurred vision.
- B. Bradycardia.
- C. Eye redness.
- D. Dry eyes.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bradycardia, which should be reported immediately.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor closely?
- A. Serum potassium.
- B. Serum sodium.
- C. Blood urea nitrogen.
- D. Blood glucose.
Correct Answer: D
Rationale: TPN contains high glucose concentrations, requiring close monitoring of blood glucose to prevent hyperglycemia.