Nokea
The nurse is planning care for a client who is taking cyclosporin (Neoral). What would be an appropriate nursing diagnosis for this client?
- A. Alteration in body image
- B. High risk for infection
- C. Altered growth and development
- D. Impaired physical mobility
Correct Answer: B
Rationale: Cyclosporin (Neoral) inhibits normal immune responses. Clients receiving cyclosporin are at risk for infection.
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A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks why, the client responds, 'Because I’m not depressed!' What is the nurse’s most appropriate response?
- A. Depression is common with fibromyalgia, but a low dose of this drug can prevent it
- B. It can relieve your chronic pain and help you sleep better at night
- C. It helps to relieve the adverse effects of your other prescribed drugs
- D. You have the right to refuse. I will notify your health care provider (HCP)
Correct Answer: B
Rationale: Duloxetine treats fibromyalgia pain and improves sleep, addressing the client’s misconception without focusing on depression. Other responses are inaccurate or dismissive.
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
- A. Maintain good nutrition
- B. Stay in school
- C. Keep in contact with the child's father
- D. Get adequate sleep
Correct Answer: A
Rationale: Maintain good nutrition. Adequate nutrition, especially protein, vitamins, and iron, is critical for healthy fetal development and reducing low-birth-weight risks.
The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?
- A. Urinary output of $60 \mathrm{ml}$ per hour
- B. Respirations of 30 per minute
- C. Absence of the knee-jerk reflex
- D. Blood pressure of $150 / 80$
Correct Answer: C
Rationale: Hypermagnesemia, a risk of magnesium sulfate therapy, causes symptoms like loss of deep tendon reflexes (e.g., knee-jerk reflex), respiratory depression, and hypotension. Urinary output of 60 ml/hour is normal, respirations of 30 suggest tachypnea, and BP of 150/80 is not specific to hypermagnesemia.
A client is brought to the emergency room with injuries sustained in an auto accident. While performing his assessment, the nurse notes the presence of Cullen's sign. Cullen's sign is suggestive of:
- A. A neurological injury
- B. A ruptured spleen
- C. A bowel perforation
- D. Retroperitoneal bleeding
Correct Answer: D
Rationale: Cullen's sign, a bluish discoloration around the umbilicus, indicates retroperitoneal or intra-abdominal bleeding, often due to trauma or conditions like pancreatitis. It is not specific to neurological injury, spleen rupture, or bowel perforation.
Which nursing action is essential in the care of an adult following a left side cardiac catheterization?
- A. Keep the client NPO for two hours.
- B. Ask the client about a shellfish allergy.
- C. Check pulses proximal to the insertion site.
- D. Check the insertion site for bleeding.
Correct Answer: D
Rationale: Checking the insertion site for bleeding is critical post-catheterization to detect hematoma or hemorrhage, ensuring patient safety.