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The nurse is caring for an 80-year-old patient who has just begun taking a Thiazide diuretic to treat hypertension. What is an important aspect of care for this patient?
- A. Providing a low potassium diet.
- B. Encouraging increased fluid intake.
- C. Initiating a fall risk protocol.
- D. Increasing exercise and activity.
Correct Answer: C
Rationale: The correct answer is C: Initiating a fall risk protocol. This is important because Thiazide diuretics can lead to electrolyte imbalances, particularly low sodium and potassium levels, which can increase the risk of falls in elderly patients. Initiating a fall risk protocol involves assessing the patient's risk factors for falls, implementing appropriate safety measures, and monitoring the patient closely to prevent falls. Providing a low potassium diet (choice A) is not necessary as Thiazide diuretics can actually lead to low potassium levels. Encouraging increased fluid intake (choice B) is important but not specific to the potential side effects of Thiazide diuretics. Increasing exercise and activity (choice D) is beneficial for overall health but not directly related to the side effects of Thiazide diuretics in this scenario.
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The nurse is caring for a patient receiving warfarin and notes bruising and petechiae on the patient's extremities. The nurse will request an order for which?
- A. Vitamin K Level.
- B. PTT and aPTT.
- C. International normalized ratio (INR).
- D. Platelet level.
Correct Answer: C
Rationale: The correct answer is C: International normalized ratio (INR). When a patient on warfarin presents with bruising and petechiae, it suggests potential over-anticoagulation. INR measures the effectiveness of warfarin therapy by assessing clotting time. An elevated INR indicates a higher risk of bleeding due to excessive anticoagulation. Ordering a Vitamin K level (choice A) is not necessary as the patient is already on warfarin. PTT and aPTT (choice B) are not specific to monitoring warfarin therapy. Platelet level (choice D) is not indicated for assessing warfarin effects.
A home care nurse administers oral morphine to the patient with cancer pain. When will the nurse expect the medication to reach peak activity?
- A. 45 minutes.
- B. 10 minutes.
- C. 30 minutes.
- D. 60 minutes.
Correct Answer: A
Rationale: The correct answer is A: 45 minutes. Oral morphine typically reaches peak activity within 30-60 minutes after administration due to its absorption rate. After ingestion, the medication passes through the stomach and intestines before entering the bloodstream, which takes time. Choice B (10 minutes) is too soon for peak activity. Choice C (30 minutes) is close but not the peak time frame. Choice D (60 minutes) is too late for peak activity.
Identify one indicator for a narcotics antagonist to be prescribed.
- A. Treatment of narcotic dependence.
- B. Treatment of alcohol dependence.
- C. Reversal of tachycardia.
- D. Reversal of bronchoconstriction.
Correct Answer: A
Rationale: The correct answer is A: Treatment of narcotic dependence. Narcotics antagonists are prescribed to counteract the effects of narcotics in the body. By blocking the receptors that narcotics bind to, these antagonists help in the treatment of narcotic dependence by reducing cravings and withdrawal symptoms. Choices B, C, and D are incorrect because narcotics antagonists are not indicated for the treatment of alcohol dependence, reversal of tachycardia, or bronchoconstriction. The key indicator for prescribing a narcotics antagonist is its specific role in addressing narcotic dependence, making choice A the correct option.
A patient who has epilepsy will begin an anticonvulsant medication. The patient asks the nurse how long the medication will be necessary. How will the nurse respond?
- A. You will take the medication as needed for seizure activity.
- B. The medication will be given until you are seizure free.
- C. You will take the medication for 3 to 5 years.
- D. The medication is usually taken for a lifetime.
Correct Answer: D
Rationale: The correct answer is D: The medication is usually taken for a lifetime. The rationale for this is that epilepsy is a chronic condition characterized by recurrent seizures. Anticonvulsant medications are typically prescribed long-term to help control and prevent seizures. Discontinuing the medication can lead to breakthrough seizures and potential risks to the patient's safety and well-being. Choices A and B are incorrect because anticonvulsants are not typically taken on an as-needed basis and the goal is not just to be seizure-free temporarily. Choice C is incorrect as the duration of anticonvulsant therapy may vary depending on the individual's condition and response to treatment, but it is often longer than 3 to 5 years.
The nurse is preparing to care for a patient who has myasthenia gravis. The nurse will be alert to symptoms affecting which body system in the patient?
- A. Gastrointestinal (GI) and lower extremity muscles.
- B. Central nervous system (CNS), memory, and cognition.
- C. Respiratory and facial muscles.
- D. Cardiovascular system and postural muscles.
Correct Answer: C
Rationale: The correct answer is C: Respiratory and facial muscles. Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. Symptoms commonly affect muscles involved in breathing (respiratory) and facial expressions, such as difficulty swallowing, breathing, speaking, and facial drooping. Monitoring these systems is crucial as respiratory muscle weakness can lead to respiratory failure. Choice A is incorrect because myasthenia gravis does not typically affect gastrointestinal or lower extremity muscles primarily. Choice B is incorrect as the primary symptoms of myasthenia gravis do not involve the central nervous system but rather the neuromuscular junction. Choice D is incorrect as myasthenia gravis does not directly impact the cardiovascular system or postural muscles.