Nokea
The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription?
- A. Diarrhea
- B. Frequent burping
- C. Headache
- D. Sucking lip motions
Correct Answer: D
Rationale: Sucking lip motions suggest tardive dyskinesia, a contraindication for metoclopramide due to risk of worsening. Diarrhea , burping , and headache are not contraindications.
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Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?
- A. Involuntary rhythmic stereotypic movements and tongue protrusion
- B. Cheek puffing, involuntary movements of extremities and trunk
- C. Agitation, constant state of motion
- D. Hyperpyrexia, severe muscle rigidity, malignant hypertension
Correct Answer: D
Rationale: Hyperpyrexia, severe muscle rigidity, and malignant hypertension are signs of neuroleptic malignant syndrome (NMS), requiring immediate discontinuation of the antipsychotic.
A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?
- A. A home health patient reports, 'I am starting to have breakdown of my heels.'
- B. A patient that received an upper extremity cast yesterday reports, 'I can't feel my fingers in my right hand today.'
- C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
- D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'
Correct Answer: B
Rationale: The patient experiencing neurovascular changes should have the highest priority. Pain following a TKR is normal, and breakdown over the heels is a gradual process. Moreover, a subacute ankle sprain is almost never a medical emergency.
An elderly client is severely dehydrated. Which is the best way to assess the effectiveness of fluid restoration therapy?
- A. Assess the client's skin turgor every shift.
- B. Record weights daily.
- C. Ask the client if she is thirsty.
- D. Record all intake.
Correct Answer: B
Rationale: Daily weights provide an objective measure of fluid restoration, as 1 kg approximates 1 L of fluid. Skin turgor is less reliable in elders, thirst is subjective, and intake alone doesn't confirm absorption.
Divalproex sodium (Depakote) is prescribed for a 28-year-old female. Which lab test would the nurse expect prior to administration of the medication?
- A. Urine drug screen
- B. Pregnancy test
- C. CBC with differential
- D. Liver function tests
Correct Answer: B
Rationale: Divalproex is teratogenic; a pregnancy test is critical in females of childbearing age to prevent fetal harm.
The nurse is talking with a client who has Huntington disease and is considering becoming pregnant. Which of the following statements would be appropriate for the nurse to make?
- A. There are alternative methods to expand your family. You should consider adoption.
- B. Genetic counseling is recommended. You will receive a referral before you leave.
- C. Huntington disease inheritance requires both biological parents to carry the gene.
- D. Huntington disease occurs spontaneously and is not likely to affect your children.
Correct Answer: B
Rationale: Huntington's is autosomal dominant, so genetic counseling is essential. Adoption dismisses the client's wishes, both parents carrying the gene is incorrect, and spontaneous occurrence is false.