Nokea
The nurse is caring for a client with a history of a seizure disorder who is receiving Carbamazepine (Tegretol). The nurse should monitor the client for:
- A. Leukopenia
- B. Hypotension
- C. Hyperglycemia
- D. Weight gain
Correct Answer: A
Rationale: Carbamazepine can cause leukopenia, requiring monitoring of white blood cell counts. Hypotension, hyperglycemia, and weight gain are not primary side effects.
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A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?
- A. Phantom pain is entirely in the client's mind. The client should be instructed that the pain is psychological and should not be treated.
- B. The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real, intense, and should be treated.
- C. The cause of phantom pain is unknown. The nurse should provide the client with support, promote sleep, and handle the injured limb smoothly and gently.
- D. Phantom pain is caused by trauma, spasms, and edema at the incisional site. It will decrease when postoperative edema decreases. It should be treated with nonnarcotic medication whenever possible.
Correct Answer: B
Rationale: This statement is entirely false. Phantom pain may be caused by nerves continuing to carry sensation to the brain even though the limb is removed. It is real, intense, and should be treated as ordinary pain would. Although the cause of phantom pain is still unknown, these measures may promote the relief of any type of pain, not just phantom pain. Phantom pain is not caused by trauma, spasms, and edema and will not be relieved by decreasing edema.
During discharge planning, parents of a child with rheumatic fever should be able to identify which of the following as toxic symptoms of sodium salicylate?
- A. Tinnitus and nausea
- B. Dermatitis and blurred vision
- C. Unconsciousness and acetone odor of the breath
- D. Chills and an elevation of temperature
Correct Answer: A
Rationale: These are toxic symptoms of sodium salicylate. (B, C, D) These are not symptoms associated with sodium salicylate.
Which measure helps reduce nipple soreness associated with breastfeeding?
- A. Feeding the baby during the first 48 hours after delivery
- B. Placing a finger between the baby's mouth and the breast to break suction after feeding
- C. Applying warm, moist soaks to the breast several times per day
- D. Wearing a support bra during the day
Correct Answer: B
Rationale: Breaking suction by placing a finger between the baby’s mouth and the breast prevents trauma to the nipple, reducing soreness. Feeding early promotes latch but doesn’t address soreness directly, warm soaks may increase inflammation, and a bra supports but doesn’t prevent nipple trauma.
Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is:
- A. 70 mg/dL and 120 mg/dL
- B. 100 mg/dL and 200 mg/dL
- C. 40 mg/dL and 130 mg/dL
- D. 90 mg/dL and 200 mg/dL
Correct Answer: A
Rationale: The recommended range is 70-120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.
The nurse has been caring for a 16-year-old female who recently experienced date rape. After having had crisis intervention and been hospitalized for 2 weeks, the nurse knows that the client is effectively coping with the rape when she tells the nurse:
- A. I know it was my fault that it happened, because I shouldn't have been out so late.'
- B. If I had not worn that sexy dress that night, he wouldn't have raped me.'
- C. I know my date just had so much passion he couldn't handle me saying 'no.'
- D. I know now that it was not my fault, but I want to continue counseling after my discharge.'
Correct Answer: D
Rationale: The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.