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The nurse is monitoring a client who is going through barbiturate withdrawal. Which symptom is of most concern to the nurse?
- A. Nausea and vomiting
- B. Anxiety
- C. Hallucinations
- D. Seizures
Correct Answer: D
Rationale: Seizures in barbiturate withdrawal are life-threatening, requiring immediate intervention, unlike nausea, anxiety, or hallucinations.
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The nurse and unlicensed assistive personnel (UAP) are caring for a client who is experiencing an acute episode of Ménière disease. Which action by the UAP would require the nurse to intervene?
- A. Assists the client to use the bedside commode
- B. Dims the lights in the client's room
- C. Places the bed in the lowest position with all side rails raised
- D. Turns off the television in the client's room
Correct Answer: C
Rationale: Raising all side rails during an acute Ménière's episode (vertigo, nausea) increases fall risk if the client attempts to climb over them. Other actions (assisting to commode, dimming lights, turning off TV) reduce stimulation and promote safety.
Which of the following instructions should be given to a client regarding testicular self-exam?
- A. The testicular exam should be done bimonthly.
- B. The testicular exam should be done while in the shower or tub.
- C. A small pen light should be used to transilluminate the scrotal sac.
- D. The testicular exam should be done yearly.
Correct Answer: B
Rationale: Testicular self-examination (TSE) is recommended monthly, not bimonthly or yearly, and is best performed during or after a warm shower or bath when the scrotum is relaxed, making it easier to detect abnormalities. Transillumination is a medical procedure, not part of TSE.
The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply.
- A. Bright red bleeding from anus
- B. Distended abdomen
- C. Has not passed stool (meconium)
- D. Nonbilious vomiting
- E. Refuses to feed
Correct Answer: B,C,D
Rationale: Hirschsprung disease causes intestinal obstruction, leading to a distended abdomen, failure to pass meconium, and nonbilious vomiting. Bright red bleeding suggests other causes (e.g., fissure). Feeding refusal is less specific.
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
- A. Macaroni and cheese
- B. Shrimp with rice
- C. Turkey breast
- D. Spaghetti and meatballs
Correct Answer: C
Rationale: Turkey contains the least amount of fat and cholesterol. Cheese, shrimp, and beef should be avoided by the client on a low cholesterol, low fat diet; therefore, answers A, B, and D are incorrect.
The nurse is preparing to administer phenytoin oral suspension via nasogastric tube to a client with a seizure disorder. The client is receiving continuous enteral feedings. Which of the following actions should the nurse take?
- A. Obtain the client's blood pressure.
- B. Check the client's pancreatic enzyme levels.
- C. Verify placement of the tube after administering the medication.
- D. Holdphysics://www.youtube.com/watch?v=9Q7sE1Xh_1QHold the enteral feeding for 1 hour before administering the medication.
Correct Answer: D
Rationale: Phenytoin binds to enteral feedings, reducing absorption. Holding feedings for 1 hour before and after administration ensures efficacy. Tube placement should be verified before, not after, administration. Blood pressure and pancreatic enzymes are unrelated.