Nokea
The nurse is obtaining a health history for a client with osteoporosis. The nurse should specifically ask the client about which of the following? Select all that apply.
- A. Amount of alcohol consumed daily.
- B. Use of antacids.
- C. Dietary intake of fiber.
- D. Use of Vitamin K supplements.
- E. Intake of fruit juices.
Correct Answer: A, B
Rationale: Excessive alcohol consumption and frequent antacid use (which may contain aluminum, reducing calcium absorption) are risk factors for osteoporosis. Fiber, vitamin K, and fruit juices are less relevant.
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The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minutes, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?
- A. Notify the physician.
- B. Administer a sedative.
- C. Try to elicit a positive Homan's sign.
- D. Increase the flow rate of intravenous fluids.
Correct Answer: A
Rationale: These symptoms suggest a possible pulmonary embolism, a life-threatening complication of DVT, requiring immediate physician notification.
A client with a history of schizophrenia is prescribed aripiprazole (Abilify). The nurse should monitor the client for which of the following adverse effects?
- A. Akathisia.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Aripiprazole can cause akathisia, a movement disorder, requiring monitoring.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which of the following flow rates is most appropriate for this client?
- A. 1-2 L/min via nasal cannula.
- B. 4-6 L/min via face mask.
- C. 8-10 L/min via non-rebreather mask.
- D. 12-15 L/min via Venturi mask.
Correct Answer: A
Rationale: A flow rate of 1-2 L/min via nasal cannula is appropriate for COPD clients to avoid suppressing their hypoxic respiratory drive.
When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.
- A. Having suction equipment readily available
- B. Keeping all the lights on in the room at night
- C. Keeping a padded tongue blade at the bedside
- D. Assisting the client to ambulate in the hallway
- E. Monitoring the client closely while showering
- F. Locking the client's bed in its lowest position
Correct Answer: A,D,E,F
Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.
A client with chronic undifferentiated schizophrenia is having an acute exacerbation of symptoms. The client states, 'Black cats and black hats. Where does the time go?' Which of the following would be most important for the nurse to say?
- A. Halloween is getting close, isn't it.'
- B. Do you have a black cat?'
- C. What's the connection between cats, hats, and time?'
- D. Time certainly does go faster these days.'
Correct Answer: C
Rationale: Clarifying the client's statement helps assess their thought process and engage therapeutically.