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The nurse is caring for a client with a history of peptic ulcer disease who is receiving omeprazole (Prilosec) 20 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache once in a while.
- B. I feel bloated after meals.
- C. I have black, tarry stools.
- D. I take my medication with breakfast.
Correct Answer: C
Rationale: Black, tarry stools suggest gastroinTest inal bleeding, a serious complication in peptic ulcer disease requiring immediate evaluation. Options A, B, and D are less concerning: headaches are nonspecific, bloating is common, and taking omeprazole with food is acceptable.
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The nurse is caring for a patient hospitalized with an acute asthma attack. The nurse would be MOST concerned if which of the following was observed?
- A. The patient becomes more diaphoretic.
- B. The patient's respirations increase from 14 to 16 per minute.
- C. The patient's pulse increases from 86 to 100 beats per minute.
- D. The patient shows increasing pallor.
Correct Answer: C
Rationale: pulse increases due to decrease in oxygenation of tissues
A client comes to the nurse's station for her antipsychotic medication. The nurse notes that the client has torticollis, an arched back, and rapid movement of the eyes.
Which of the following action should the nurse take FIRST?
- A. Determine what other medications the patient is taking.
- B. Perform a neurological assessment.
- C. Administer haloperidol decanoate (Haldol D) IM stat.
- D. Administer the PRN trihexyphenidyl (Artane) IM immediately.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) assessment, demonstrating acute extrapyramidal side effects (2) assessment, no validation required (3) Haldol is antipsychotic, will exacerbate symptoms (4) correct-administer Cogentin or Artane
A client comes to the clinic complaining of severe facial pain. In order to collect subjective data from the client, it is MOST important for the nurse to
- A. obtain the client's vital signs.
- B. interview the client.
- C. inspect the face for grimacing.
- D. administer pain medication.
Correct Answer: B
Rationale: subjective data is collected in the health history or interview
A patient received meperidine (Demerol) 75 mg IM 2 hours ago for complaints of pain. The patient turns on his call light and tells the nurse he has to go to the bathroom. The physician has ordered BPR (bathroom privileges). The nurse should
- A. obtain a bedside commode for the patient's use and provide privacy.
- B. help the patient to sit on the side of the bed before proceeding to the bathroom.
- C. provide a bedpan for the patient's use and pull the curtains.
- D. get another nurse and together assist the client to the bathroom.
Correct Answer: B
Rationale: side effects of medication include decreased BP, orthostatic hypotension, bradycardia
The nursing staff is planning to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program?
- A. Monitor the client's ability to complete her activities of daily living (ADL).
- B. Assess the client's levels of pain and correlate it with her response to analgesia.
- C. Observe the client's behavior at regular intervals to obtain baseline information related to her screaming.
- D. Ask the client why she is screaming and document it on her nursing assessment record.
Correct Answer: C
Rationale: to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors