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The nurse is caring for the child from Italy. The child is crying, and the interpreter is stating that the child has extreme pain. What should be the nurse's priority?
- A. Administer morphine sulfate 1 mg intravenously as prescribed.
- B. Have the child's mother, who knows limited English, ask the child what hurts.
- C. Assess the level of the child's pain using an appropriate FACES pain rating scale.
- D. Ask the HCP to change the pain medication dosage due to inadequate pain control.
Correct Answer: C
Rationale: A: The nurse's judgment regarding the choice of pain medication and dose should be based on the reported level of pain. B: The nurse should do an independent assessment because sometimes information can be misinterpreted if there is limited knowledge of the language. C: Assessment should be completed prior to a pain intervention. The FACES pain-rating scale has been translated into a variety of languages. D: There is no information indicating the need for the pain medication dose to be changed.
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The nurse is reviewing client information for adverse effects of trazodone. Which finding should the nurse identify as an adverse effect unique to trazodone?
- A. Priapism
- B. Weight gain
- C. Hepatic failure
- D. Cardiac dysrhythmias
Correct Answer: A
Rationale: Prolonged or inappropriate erections (priapism) are a rare but problematic side effect of treatment with trazodone (Oleptro).
The clinic nurse is reviewing prescriptions with the parents of the school-aged child with newly diagnosed generalized contact dermatitis. Which prescription should the nurse question with the HCP?
- A. Oral prednisone
- B. Calamine lotion
- C. Oral diphenhydramine
- D. Hydrocortisone cream
Correct Answer: A
Rationale: A: Prednisone (Deltasone) would not be a first-line treatment for contact dermatitis, and its use should be questioned. Prednisone may be added later if the contact dermatitis has not resolved. B: Calamine lotion is used to promote drying and help relieve itching. C: Diphenhydramine (Benadryl) helps to relieve itching. D: Hydrocortisone cream is an anti-inflammatory agent used to treat contact dermatitis.
Melissa Smith came to the Emergency Department in the last week before her estimated date of confinement complaining of headaches, blurred vision, and vomiting. Suspecting PIH, the nurse should best respond to Melissa's complaints with which of the following statements?
- A. The physician will probably want to admit you for observation.'
- B. The physician will probably order bed rest at home.'
- C. These are really dangerous signs.'
- D. The physician will probably prescribe some medicine for you.'
Correct Answer: B
Rationale: Pregnancy-induced hypertension (PIH) symptoms like headaches, blurred vision, and vomiting suggest preeclampsia, which is best managed with bed rest at home unless severe, requiring hospitalization.
The parent of the child brought to the ED states to the nurse, “My child is sweaty and shaky; I think some of my medication is gone.†The parent hands the nurse the medication bottle illustrated. Which action should the nurse take first?
- A. Start an infusion of D5W at 40 mL/hr.
- B. Give glucagon 1 mg subcutaneously.
- C. Check the child's blood glucose level.
- D. Determine how many tablets were taken.
Correct Answer: C
Rationale: A: Initiating an IV access for glucose administration is more time-consuming than giving glucose by the oral route or glucagon (GlucaGen) subcutaneously to a child who is still responsive. B: An oral form of glucose should be administered if the child is responsive and glucagon given only if the child is unresponsive or too uncooperative or upset to take oral glucose. Glucagon stimulates the release of liver glycogen and releases glucose into the circulation. C: The child may have ingested the glipizide (Glucotrol XL), a sustained-released hypoglycemic agent. The child's blood glucose level should be checked first to determine the appropriate treatment. D: Determining the number of tablets taken may delay the child's treatment.
The client, hospitalized with an exacerbation of SLE, is to receive methylprednisolone 20 mg IV q8h. Which intervention should the nurse anticipate being included in the client's plan of care?
- A. Take orthostatic BPs at least twice daily.
- B. Administer a stool softener twice daily.
- C. Premedicate with diphenhydramine.
- D. Check blood glucose before meals and at bedtime.
Correct Answer: D
Rationale: A: Clients receiving systemic corticosteroids are at risk for hypertension, not orthostatic hypotension. B: Constipation is not an adverse effect of corticosteroid therapy. C: Antihistamine medications are not used before administration of corticosteroids. D: Methylprednisolone (Medrol, Solu-Medrol) is a corticosteroid. Therapy with corticosteroids causes hyperglycemia. The blood glucose level should be monitored.