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The nurse is caring for a client with a history of depression who is receiving bupropion (Wellbutrin) 150 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a dry mouth.
- B. I feel restless sometimes.
- C. I think about ending my life.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of ending life indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on bupropion. Options
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An adult is admitted with histoplasmosis. What is most likely to be in the client's history because he has histoplasmosis?
- A. He is a chicken farmer.
- B. He ate raw shellfish recently.
- C. He consumed contaminated water.
- D. He drinks raw milk.
Correct Answer: A
Rationale: Histoplasmosis is caused by inhaling Histoplasma spores, often found in bird or bat droppings, common in chicken farming environments, unlike shellfish, water, or milk.
The home nurse who is caring for an older person who has chronic obstructive pulmonary disease (COPD) with continuous nasal oxygen is helping the family set up a humidifier in the room. The humidifier cord is not long enough to reach the outlet in the room and must be plugged into an extension cord. The extension cord is wrapped with black tape. When the nurse asks the family members about the tape, they reply that the cord is an old cord, and the electrical tape covers up the frayed part and makes it safe. They say a contractor friend told them how to make it safe. How should the nurse respond?
- A. Refuse to set up the equipment until a new cord is available
- B. Carefully inspect the taped area and set up equipment if it appears intact
- C. Ask the family to let the nurse discuss the safety of the cord with the contractor friend
- D. Set up the equipment and suggest that the family get a new extension cord as soon as possible
Correct Answer: A
Rationale: A frayed cord poses a fire hazard, especially with oxygen use. Refusing to set up until a safe cord is available prioritizes safety.
A client is diagnosed with bipolar disorder and is in a manic phase with combative behavior.
An INITIAL nursing priority is to
- A. provide adequate hygiene and nutrition.
- B. decrease environmental stimuli.
- C. slowly involve the client in unit activities.
- D. administer and monitor sedative and mood-stabilizing medications.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority (2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression (3) this action is inappropriate at this time (4) correct-is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents
Which instruction should be given to the client taking alendronate sodium (Fosamax)?
- A. Take the medication before arising.
- B. Force fluids while taking this medication.
- C. Remain upright for 30 minutes after taking this medication.
- D. Take the medication in conjunction with estrogen.
Correct Answer: C
Rationale: Alendronate sodium is a drug used to treat osteoporosis. The drug causes gastric reflux, so the client should remain upright for 30 minutes after taking it and take it with only water. Taking it before arising or with estrogen is incorrect, and forcing fluids is not necessary.
A client with signs of increased intracranial pressure (ICP).
In planning care for a client with signs of increased intracranial pressure (ICP), the nurse would include which of the following?
- A. Encourage coughing and deep breathing to prevent pneumonia.
- B. Suction the airway every 2 hours to remove secretions.
- C. Position the client in the prone position to promote venous return.
- D. Determine cough reflex and ability to swallow prior to administering PO fluids.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) increases intracranial pressure (2) increases intracranial pressure (3) head of the bed should be elevated 15 to 30° to promote venous drainage (4) correct-assessment, cough or gag reflex and the swallowing reflex may be affected by the increased pressure; increases the incidence of aspiration