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The nurse is conducting an admission assessment on a patient. When collecting data relating to the medications, the nurse asks “What medications are you taking?†After collecting that information, what other queries should the nurse ask? Select all that apply.
- A. Do you take any medication?
- B. Do you take this medication?
- C. Do you take medications safely when you take them?
- D. Do you take any herbs, vitamins or supplements?
- E. What OTC medications do you take?
Correct Answer: D,E
Rationale: The correct answers are D and E. Asking about herbs, vitamins, and supplements (D) is crucial as these can interact with prescribed medications. Inquiring about over-the-counter (OTC) medications (E) is important as they can also have interactions. Choices A, B, and C are vague and redundant, as they do not provide specific information about medications. Asking about medication safety (C) is assumed in the context of a healthcare setting. Choice F and G are not provided in the question.
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Vitamin D plays an important part in the absorption of calcium by the body. Where is vitamin D activated into a form that promotes calcium absorption?
- A. Small intestine.
- B. Vitamin D is not activated into another form.
- C. Kidneys.
- D. Large intestine.
Correct Answer: C
Rationale: The correct answer is C: Kidneys. Vitamin D undergoes two hydroxylation steps for activation - first in the liver and then in the kidneys. The final active form of vitamin D, calcitriol, is produced in the kidneys. Calcitriol promotes the absorption of calcium in the intestines. The small intestine (Choice A) is where calcium is absorbed, but vitamin D is activated in the kidneys. Vitamin D does undergo activation into another form as mentioned above, so choice B is incorrect. The large intestine (Choice D) is primarily involved in water absorption, not vitamin D activation.
A nurse is providing discharge teaching for a patient who will be going home on cyclobenzaprine (Flexeril) prescribed for his acute musculoskeletal pain. The nurse will stress that the patient should avoid what?
- A. Taking antihistamines.
- B. Taking antiemetics.
- C. Taking antibiotics.
- D. Drinking alcohol.
Correct Answer: D
Rationale: The correct answer is D: Drinking alcohol. Cyclobenzaprine is a muscle relaxant that can cause drowsiness and dizziness. Alcohol can intensify these side effects, leading to impaired coordination and judgment. This can increase the risk of accidents and falls. It is important for the patient to avoid alcohol while taking cyclobenzaprine to prevent these adverse effects.
Choices A, B, and C are incorrect because there are no known interactions between cyclobenzaprine and antihistamines, antiemetics, or antibiotics that would pose a significant risk to the patient. It is essential to focus on the potential interactions that can have serious consequences, such as alcohol with cyclobenzaprine.
The patient newly diagnosed with epilepsy asks the nurse to explain the meaning of the diagnosis. What is the nurse's best response?
- A. Epilepsy is the clonic-tonic muscle contraction with the potential to cause injury.
- B. Epilepsy is a convulsive disorder caused by electrical discharge in the muscle.
- C. Epilepsy is a single disease.
- D. Epilepsy is characterized by sudden discharge of electrical energy.
Correct Answer: D
Rationale: The correct answer is D because epilepsy is defined by sudden discharges of electrical energy in the brain leading to seizures. This explanation is accurate and specific to the condition. Choice A is incorrect because epilepsy encompasses various types of seizures, not just clonic-tonic muscle contractions. Choice B is incorrect as it simplifies epilepsy to being solely convulsive, disregarding non-convulsive seizures. Choice C is incorrect because epilepsy is a spectrum of disorders.
The parent of a 5-year-old child asks the nurse to recommend an over-the-counter pain medication for the child. Which analgesic will the nurse recommend?
- A. Acetaminophen (Tylenol).
- B. Ibuprofen (Motrin).
- C. Aspirin (Ecotrin).
- D. Diflunisal (Dolobid).
Correct Answer: A
Rationale: The correct answer is A: Acetaminophen (Tylenol). Acetaminophen is recommended for children due to its safety profile and effectiveness in reducing pain and fever. Ibuprofen and aspirin can be used in children over 6 months old, but aspirin is not recommended for children due to the risk of Reye's syndrome. Diflunisal is not typically used in children. In summary, acetaminophen is the safest and most appropriate choice for a 5-year-old child's pain relief.
A 70-year-old patient has just received a drug that can cause sedation. What would be the priority nursing diagnosis for this patient?
- A. Deficient Knowledge, unfamiliar with drug therapy.
- B. Ineffective health maintenance, need for medication.
- C. Risk for injury, related to adverse effect of the drug.
- D. Noncompliance, cost of the drug.
Correct Answer: C
Rationale: The correct answer is C: Risk for injury, related to adverse effect of the drug. This is the priority nursing diagnosis because the patient, being 70 years old and receiving a sedating drug, is at an increased risk for falls and other injuries due to sedation. It is crucial for the nurse to monitor the patient closely for signs of sedation and take appropriate measures to prevent potential harm.
Choice A (Deficient Knowledge) is not the priority as the immediate concern is the risk of injury. Choice B (Ineffective health maintenance) focuses on the need for medication, not the potential risk of injury. Choice D (Noncompliance) is not relevant in this situation as it pertains to the cost of the drug, not the immediate safety of the patient.