Nokea
The nurse is reviewing the medication administration record for a 70-year-old client. Which of the following prescribed medications places the client at increased risk for injury? Select all that apply.
- A. diphenhydramine
- B. amitriptyline
- C. simvastatin
- D. famotidine
- E. diazepam
Correct Answer: A,B,E
Rationale: Diphenhydramine (A), amitriptyline (B), and diazepam (E) cause sedation or confusion, increasing fall risk in the elderly. Simvastatin (C) and famotidine (D) do not significantly increase injury risk.
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A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by
- A. Requiring the client to mop the floor
- B. Restricting the client's fluids throughout the day
- C. Withholding privileges each time the voiding occurs
- D. Toileting the client more frequently with supervision
Correct Answer: D
Rationale: Toileting the client more frequently with supervision. This approach addresses the physical need in a client with altered thought processes.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
The nurse has been teaching a woman who has iron deficiency anemia. Which menu, if selected, indicates that the woman understands her dietary instructions?
- A. Applesauce, green beans, bread, and butter
- B. Peanut butter and jelly sandwich, carrots, and milk
- C. Broccoli, spinach salad with tomatoes, and orange juice
- D. Macaroni and cheese, pickles, and hot chocolate
Correct Answer: C
Rationale: Broccoli, spinach, and orange juice (vitamin C enhances iron absorption) are iron-rich, ideal for anemia. Other menus lack sufficient iron sources.
The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Attaches an 18-gauge injection needle to a syringe for withdrawal of medication
- B. Breaks the ampule neck away from the nurse's body to prevent injury from the glass
- C. Disposes of the empty glass ampule in a sharps container
- D. Injects air into the glass ampule prior to withdrawing the medication
- E. Rests and steadies the needle on the ampule's outer rim to withdraw medication
Correct Answer: B,C
Rationale: Breaking the ampule away from the body (B) and disposing in a sharps container (C) are safe practices. An 18-gauge needle (A) is too large, injecting air (D) is unnecessary, and resting the needle on the rim (E) risks contamination.
A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider?
- A. Diarrhea, vomiting, and mild tremor
- B. Dry mouth and mild thirst
- C. Hyperactivity and auditory hallucinations
- D. Lithium level of 1.3 mEq/L (1.3 mmol/L)
Correct Answer: A
Rationale: Diarrhea, vomiting, and tremor (A) suggest lithium toxicity, requiring immediate reporting. Dry mouth (B) is common, hallucinations (C) are unrelated, and a lithium level of 1.3 (D) is within therapeutic range.