Nokea
The nurse is caring for a client with a history of bipolar disorder who is receiving valproic acid (Depakote) 500 mg PO bid. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Liver enzymes elevated to twice normal.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: Elevated liver enzymes suggest hepatotoxicity, a serious side effect of valproic acid, requiring immediate evaluation to prevent liver failure. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
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The nurse is caring for an adult who is enrolled in a study involving an experimental drug. The client says to the nurse, 'I don't think I can stand the vomiting anymore. I think it is due to the drug I am taking. If only I could get out of this study I signed up for. That was a really stupid thing I did when I signed up for the study.' What information must the nurse include when responding to the client?
- A. If the client signed the proper forms, the client is committed to the study.
- B. Persons who have signed up for a study may opt out of the study at any time.
- C. The person should discuss his/her concerns with the researchers.
- D. Inform the client that there are drugs that can control nausea.
Correct Answer: B
Rationale: Participants can withdraw from research studies at any time, per ethical research guidelines, ensuring autonomy and safety.
A two-year-old who is one-day postoperative.
The mother of a two-year-old who is one-day postoperative tells the nurse, 'My child is so restless and overactive.' The nurse should
- A. direct the LPN/LVN to obtain the child's vital signs.
- B. ask the mother if the child's sutures are still intact.
- C. tell the nursing assistant to take the child for a walk.
- D. check to see when the child last received pain medication.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment. (1) no indication that there are any problems (2) passing the buck (3) implementation, should first assess (4) correct-young children typically become restless and overactive if in pain, grimacing, clenching teeth, rocking, and aggressive behavior may also be observed
A client admitted with tuberculosis asks the nurse how long he will have to take his prescription for INH. The best answer for the nurse to give the client is:
- A. It depends on the type of tuberculosis you have.'
- B. You will need to take the INH for approximately 6 months.'
- C. After about 6 weeks, the doctor will discontinue the medication.'
- D. You will remain on INH for an indefinite time period.'
Correct Answer: B
Rationale: INH (isoniazid) treatment for active tuberculosis typically lasts 6-9 months. Six weeks is too short, and indefinite treatment is incorrect.
A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck.
- A. Which PRN medication should the nurse expect to give for a client with extrapyramidal side effects from perphenazine?
- B. Promazine (Sparine).
- C. Biperiden (Akineton).
- D. Thiothixene (Navane).
- E. Haloperidol (Haldol).
Correct Answer: B
Rationale: Biperiden, an antiparkinsonian agent, counteracts extrapyramidal side effects (e.g., dystonia, stiffness) caused by antipsychotics like perphenazine. Promazine, thiothixene, and haloperidol are antipsychotics that could worsen these side effects.
An adult male is admitted with urolithiasis. The nurse expects which orders for this client? Select all that apply.
- A. Push fluids
- B. Strain all urine
- C. Medicate for pain PRN
- D. Clean catch daily
- E. Daily catheterizations
- F. Clear liquid diet
Correct Answer: A,B,C
Rationale: Pushing fluids promotes stone passage, straining urine captures stones for analysis, and pain medication addresses colic in urolithiasis. Clean catch, catheterization, or clear liquids are not standard.