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The nurse is performing an admission assessment on a stable patient admitted after a motor vehicle accident. The patient reports having bad pain. What will the nurse do first?
- A. Attempt to determine what type of pain the patient has.
- B. Request an order for intravenous opioid analgesic.
- C. Administer acetaminophen (Tylenol).
- D. Ask the patient to rate the pain on a scale of 1-10.
Correct Answer: D
Rationale: The correct answer is D: Ask the patient to rate the pain on a scale of 1-10. This is the first step in assessing pain intensity, which helps determine the urgency and appropriate interventions needed. By having the patient rate the pain, the nurse can establish a baseline for pain management and monitor effectiveness of interventions.
Choice A is incorrect because determining the type of pain comes after assessing the intensity. Choice B is incorrect as requesting IV opioids without assessing pain intensity first may not be appropriate for a stable patient. Choice C is incorrect as administering acetaminophen should be based on the pain assessment.
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The nurse is performing an assessment on a patient who will begin taking propranolol (Inderol) to treat hypertension. The nurse learns that the patients have a history of asthma and diabetes. The nurse will take which action.
- A. Request an order for a renal function test prior to the administration of this drug.
- B. Teach the patient about the risk of combining herbal medication with this drug.
- C. Contact the doctor to discuss another type of antihypertensive medication.
- D. Administer the medication and monitor the patient's serum glucose level.
Correct Answer: C
Rationale: Correct Answer: C - Contact the doctor to discuss another type of antihypertensive medication.
Rationale: Propranolol is a non-selective beta-blocker that can exacerbate asthma due to its potential bronchoconstrictive effects. Additionally, beta-blockers can mask signs of hypoglycemia in patients with diabetes, making it challenging to monitor blood glucose levels effectively. Therefore, it is crucial for the nurse to contact the doctor to discuss an alternative antihypertensive medication that is safe for the patient with a history of asthma and diabetes.
Summary of other choices:
A: Requesting a renal function test is not directly related to the patient's history of asthma and diabetes, which are more concerning in this case.
B: Teaching about combining herbal medication does not address the potential risks of propranolol in patients with asthma and diabetes.
D: Administering the medication without addressing the compatibility with the patient's conditions can lead to adverse effects and is not
The nurse receives an order for a triptan for a patient diagnosed with a cluster headache. What drug should be indicated for this purpose?
- A. Sumatriptan (Imitrex).
- B. Naratriptan (Amerge).
- C. Frovatriptan (Frova).
- D. Almotriptan (Axert).
Correct Answer: A
Rationale: The correct answer is A: Sumatriptan (Imitrex). Sumatriptan is the drug of choice for treating cluster headaches due to its rapid onset of action and high efficacy in relieving symptoms. It works by constricting blood vessels in the brain and blocking pain pathways. Naratriptan, Frovatriptan, and Almotriptan are also triptans but are not as effective or fast-acting as Sumatriptan for cluster headaches. Therefore, they are not the ideal choice. Summarily, Sumatriptan is the preferred option for managing cluster headaches due to its quick and potent action compared to other triptans.
A patient has been taking Sertraline (Zoloft) 20mg/ml oral concentrate 1ml daily for several weeks and reports being unable to sleep well. What will the nurse do next?
- A. Ask the patient what time of day the medication is taken.
- B. Recommend asking the provider about weekly dosage.
- C. Counsel the patient to take the medication at bedtime.
- D. Suggest that the patient request a lower dose.
Correct Answer: A
Rationale: The correct answer is A: Ask the patient what time of day the medication is taken. This is because insomnia can be a common side effect of sertraline, and taking it at a different time of day may help alleviate this issue. By understanding the timing of the medication intake, the nurse can assess if adjusting the administration time may improve the patient's sleep. Option B is not directly related to addressing the sleep concern. Option C may help but does not address the timing issue. Option D is premature without assessing the current timing.
A patient is admitted to the emergency department with severe recurrent convulsive seizures. Would the nurse expect to order for the use in emergency control of status epileptic?
- A. Ethosuximide (Zarontin).
- B. Diazepam (Valium).
- C. Phenobarbital (Luminal).
- D. Phenytoin (Dilantin).
Correct Answer: B
Rationale: The correct answer is B: Diazepam (Valium). In emergency situations of status epilepticus, diazepam is the preferred medication for immediate control of seizures due to its fast onset of action and efficacy in stopping prolonged seizures. Diazepam acts by enhancing the effect of gamma-aminobutyric acid (GABA) in the brain, which inhibits excessive neuronal activity. Ethosuximide (A) is used for absence seizures, not convulsive seizures. Phenobarbital (C) and phenytoin (D) have slower onset of action and are not ideal for immediate control of seizures.
The nurse is caring for a patient that has seizure disorder. The nurse notes that the patient has reddened gums that bleed when oral care is given. The nurse recognizes this finding as:
- A. A sign of poor self-care.
- B. A drug interaction with aspirin.
- C. An adverse effect of the phenytoin.
- D. A symptom of hepatotoxicity.
Correct Answer: C
Rationale: The correct answer is C: An adverse effect of phenytoin. Phenytoin is an antiepileptic drug known to cause gingival hyperplasia, leading to reddened and bleeding gums. This is a common side effect of phenytoin due to its effect on gingival tissues. Poor self-care (choice A) may contribute to gingival issues, but in this case, the patient's gums are affected by a medication side effect. There is no indication in the question of aspirin use (choice B) or hepatotoxicity (choice D) causing the gum issues. Therefore, the most likely explanation is the adverse effect of phenytoin.