Nokea
The nurse is caring for a client with a history of anxiety who is receiving lorazepam (Ativan) 0.5 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel drowsy in the morning.
- B. I have a dry mouth.
- C. I feel dizzy when I stand up.
- D. I take my medication with food.
Correct Answer: C
Rationale: Dizziness upon standing suggests orthostatic hypotension, a serious side effect of lorazepam, increasing fall risk and requiring evaluation. Options A, B, and D are less concerning: drowsiness and dry mouth are common, and taking with food is acceptable.
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A LPN/LVN contacts the nurse to say that s/he has shingles on her/his back. Which of the following statements by the nurse is BEST?
- A. You can't take care of clients for fourteen days.
- B. Come to work as scheduled.
- C. You can't care for clients until the lesions are crusted.
- D. Please contact your physician.
Correct Answer: B
Rationale: Localized shingles allows work if lesions are covered, as with back lesions. Options A, C, and D are overly restrictive or unnecessary.
The nurse is caring for a client with asthma who has developed gastroesophageal reflux disease (GERD). Which of the following medications prescribed for the client may aggravate GERD?
- A. Anticholinergics
- B. Corticosteroids
- C. Histamine blocker
- D. Antibiotics
Correct Answer: A
Rationale: An anticholinergic medication will decrease gastric emptying and the pressure on the lower esophageal sphincter.
A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?
- A. Holistic healing
- B. Spiritual advising
- C. Herbal preparations
- D. Witchcraft potions
Correct Answer: A
Rationale: Holistic healing. This traditional folk practitioner uses holistic methods for illnesses, often working with traditional health care providers.
An adult is admitted to the nursing care unit. He begs the nurse to give him a laxative. Which data in the admission assessment contraindicates administration of a laxative?
- A. The client has not had a bowel movement for two days.
- B. The client has a temperature of 100.8°F.
- C. The client is nauseated and vomited before admission.
- D. The client has right lower quadrant abdominal pain.
Correct Answer: D
Rationale: Right lower quadrant pain may indicate appendicitis or other acute conditions; laxatives could worsen the condition, risking perforation. Two days without a bowel movement, mild fever, or nausea do not contraindicate laxatives.
The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Dry mouth.
- B. Mild sedation.
- C. Muscle stiffness and tremors.
- D. Insomnia.
Correct Answer: C
Rationale: Muscle stiffness and tremors suggest extrapyramidal symptoms, a serious haloperidol side effect. Options A, B, and D are less urgent.