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The nurse is caring for an elderly client and providing education. Which of the following would be least appropriate?
- A. The nurse speaks in a loud voice.
- B. The nurse allows additional time after each instruction to allow the client to process.
- C. The nurse provides supplemental written resources.
- D. The nurse breaks up the education into multiple shorter sessions.
Correct Answer: A
Rationale: The nurse should not speak in a loud voice just because the client is elderly. The nurse should assess the client for a hearing impairment to see if additional assistance is required. However, elderly clients tend to require more time to process information, since their reaction time is slower, and they may benefit from more frequent, shorter sessions as they fatigue easily. Elderly clients are usually capable of absorbing supplemental written resources.
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The hospitalized child who has a blood lead level of 50 mcg/dL is to receive succimer 10 mg/kg oral capsule q8h for 5 days. The child weighs 20 kg. Which intervention by the student nurse should be corrected by the observing nurse?
- A. Prepares to give the total dose of one 100-mg capsule with applesauce
- B. Sprinkles the beads of two 100-mg capsules into pudding for administration
- C. Offers fluids frequently during the shift to increase the child's urine output
- D. Explains to a parent that chelation therapy removes the lead from the blood
Correct Answer: A
Rationale: A: The 20-kg child should receive two capsules of succimer (Chemet), not one. Dose (mg) = 20 kg x 10 mg/kg = 200 mg. B: Succimer capsules can be opened and sprinkled on a small amount of food or in liquid to be swallowed; two 100-mg capsules = 200 mg, which is the correct dose. C: Fluids should be increased to prevent renal damage because succimer is excreted by the kidneys. D: Succimer forms a water-soluble compound with lead, allowing urinary elimination of excessive amounts of lead. Lead is removed from the blood, and theoretically some lead is removed from tissues and organs.
The best lab test to diagnose disseminated intravascular coagulation (DIC) is:
- A. platelet count
- B. protime (PT)
- C. partial thromboplastin time (PTT)
- D. D-dimer
Correct Answer: D
Rationale: The D-dimer test specifically detects fibrin degradation products, indicating DIC's characteristic clotting and fibrinolysis. Other tests are less specific.
The 6-month-old hospitalized with dehydration is being rehydrated with IV fluids. Which findings should indicate to the nurse that the treatment is having the desired effect? Select all that apply.
- A. Flat fontanelle
- B. Absence of crying
- C. Light yellow urine
- D. Rapid respirations
- E. Moist mucous membranes
Correct Answer: A,C,E
Rationale: A: Flat (rather than depressed) fontanelles indicate good hydration, which is the desired effect of IV rehydration. B: Absence of crying is not related to improved hydration status. C: Light-colored urine indicates good hydration, which is the desired effect of IV rehydration. D: Rapid respirations may indicate dehydration. E: Moist mucous membranes indicate good hydration, which is the desired effect of IV rehydration.
The nurse is preparing an educational program on immunizations for parents of children 11 to 12 years of age. To ensure the information presented is accurate for this age group, which immunizations should the nurse plan to address?
- A. Haemophilus influenza, varicella, and human papillomavirus (HPV)
- B. Mumps, measles, and rubella (MMR); pneumococcal (PPSV); and hepatitis A
- C. Diphtheria-tetanus-pertussis (DTaP), meningococcal, and haemophilus influenza
- D. Mumps, measles, and rubella (MMR); diphtheria-tetanus-pertussis (DTaP); and hepatitis B
Correct Answer: C
Rationale: A: Varicella vaccines are administered at 12 to 15 months, with the second dose at 4 to 6 years. B: The first dose of hepatitis A vaccine is administered before 1 year of age, with the second dose 6 months after the first dose. C: The recommended immunization schedule for children 11 to 12 years old includes a DTaP booster and meningococcal and haemophilus influenza vaccines. Others include HPV, PPSV, and hepatitis A series. D: MMR vaccines are administered at 12 to 15 months, with the second dose at 4 to 6 years. A hepatitis B vaccine is administered to all newborns prior to hospital discharge, with the second dose at 1 to 2 months and the third dose at 6 to 18 months.
The client admitted for inpatient treatment of an anxiety disorder has been taking fluoxetine for the past 9 months. The HCP prescribes a new antianxiety medication and discontinues fluoxetine. What is the nurse's most appropriate intervention?
- A. Monitor the client closely for dizziness and lethargy due to discontinuation syndrome.
- B. Teach the client relaxation measures to use while adjusting to the new antianxiety drug.
- C. Call the HCP to question whether fluoxetine should be iżtapered rather than discontinued.
- D. Reassure the client that there is little risk of adverse effects when discontinuing fluoxetine.
Correct Answer: D
Rationale: Because of its long half-life, there is a relatively low risk of adverse effects when discontinuing fluoxetine (Prozac). The client should be reassured and taught about the change of antianxiety medication.