The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?
- A. I need to enroll in a smoking cessation program.
- B. I need to restrict the amount of potassium in my diet.
- C. I will lie down and avoid walking unassisted during acute attacks.
- D. I will limit the amount of caffeine and alcohol that I consume.
Correct Answer: B
Rationale: Restricting potassium isn't indicated for Ménière's disease; a low-sodium diet is typically recommended to reduce fluid retention. Smoking cessation, lying down during attacks, and limiting caffeine/alcohol are appropriate.
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The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dry, shiny, hairless skin on the affected extremity
- B. warmth and redness of the affected extremity
- C. reports of pain in the affected calf
- D. edema of the affected extremity
- E. cyanosis of the affected toes
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.
A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?
- A. Suggest isometric exercises
- B. Maintain the client on bed rest
- C. Ambulate for several minutes
- D. Apply ice to the extremity
Correct Answer: B
Rationale: Maintain the client on bed rest. The finding suggests deep vein thrombosis. The client must be maintained on bed rest and the provider notified immediately.
The nurse is talking with the parent of a pediatric client with attention deficit hyperactivity disorder who has a new prescription for methylphenidate. The parent asks, 'How will I know that the medication is effective?' Which of the following responses would be appropriate for the nurse to make?
- A. Your child will be less irritable.
- B. Your child will sleep longer at night.
- C. Your child will experience an increased appetite.
- D. Your child will complete tasks more easily and efficiently.
Correct Answer: D
Rationale: Methylphenidate improves focus and task completion in ADHD. It may increase irritability or decrease appetite as side effects, and sleep patterns vary but aren't a primary indicator of effectiveness.
The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply.
- A. Alanine aminotransferase from 20 U/L (0.33 ukat/L) to 80 U/L (1.34 ukat/L)
- B. High-density lipoprotein cholesterol from 48 mg/dL (1.24 mmol/L) to 30 mg/dL (0.78 mmol/L)
- C. Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L)
- D. Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L)
- E. Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L)
Correct Answer: C,D,E
Rationale: Rosuvastatin, a statin, is expected to lower LDL cholesterol, total cholesterol, and triglycerides, indicating therapeutic response. An increase in alanine aminotransferase suggests liver stress, which is a side effect to monitor, not a therapeutic goal. A decrease in HDL cholesterol is undesirable, as statins typically maintain or increase HDL.
An adult is taking phenazopyridine hydrochloride (Pyridium) 200 mg PO tid after meals. Which comment by the client indicates a lack of understanding about the medication?
- A. If I take my medications after meals, I avoid upsetting my stomach.'
- B. I am concerned that my urine is bright orange.'
- C. I do not have as great an urge to urinate since I have been on Pyridium.'
- D. I have to let my doctor know if my skin or eyes turn yellow.'
Correct Answer: B
Rationale: Bright orange urine is a normal effect of Pyridium, so concern about it indicates a lack of understanding of the medication's side effects.
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