Nokea
The nurse is talking to a client with a newly diagnosed seizure disorder who has a prescription for levetiracetam. Which of the following statements by the client would require follow-up?
- A. I can begin driving my car again after I have been taking this medication for 2 weeks
- B. I need to contact my health care provider if I develop a rash while taking this medication
- C. I should report any new or increased anxiety I experience while taking this medication
- D. I understand that drowsiness is an adverse effect of this medication that may improve over time.
Correct Answer: A
Rationale: Driving restrictions for seizure disorders typically last 6-12 months seizure-free, not 2 weeks, posing a safety risk. Reporting rashes and anxiety are correct due to potential side effects of levetiracetam.
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Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0
The nurse recognizes which of the following factors as possibly contributing to a sentinel event?
- A. Administered warfarin to a client with an INR of 6.0
- B. Administered flumazenil to a client who overdosed on lorazepam
- C. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
- D. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
Correct Answer: A
Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.
A client is admitted with a head injury. Which vital sign assessment is most indicative of increased intracranial pressure?
- A. BP 120/80, pulse 120, respirations 20
- B. BP 180/98, pulse 50, temperature 102°F
- C. BP 98/60, pulse 132, temperature 97.6°F
- D. BP 170/90, pulse 80, respirations 24
Correct Answer: B
Rationale: Vital signs correlating with increased intracranial pressure are an elevated BP with a widening pulse pressure, a slow pulse rate, and an elevated temperature with involvement of the hypothalamus. Answer C relates to hypovolemia, so it is incorrect. Answers A and D do not relate to increased intracranial pressure and are therefore incorrect.
The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply.
- A. History of angioedema with lisinopril
- B. History of epilepsy
- C. Known allergy to avocados and bananas
- D. Known allergy to shellfish
- E. Lip swelling when blowing up balloons
Correct Answer: C,E
Rationale: Allergies to avocados, bananas, and latex (balloons) indicate a potential latex allergy due to cross-reactivity. Angioedema with lisinopril, epilepsy, and shellfish allergies are unrelated to latex sensitivity.
The nurse has reinforced teaching with the parent of a 4-month-old with gastroesophageal reflux. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.
- A. I will feed my baby smaller amounts more frequently
- B. I will place my baby in a side-lying position at night for sleep
- C. I will dilute my baby’s formula with water to decrease regurgitation
- D. I should massage my baby’s belly as soon as each feeding is complete
- E. I should hold my baby in an upright position for 20 to 30 minutes after each feeding
Correct Answer: A,E
Rationale: Smaller, frequent feedings and upright positioning reduce reflux. Side-lying is unsafe for sleep, diluting formula risks malnutrition, and massaging the belly post-feeding may increase regurgitation.
The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ('knocked out'). After recovering the tooth, the initial response should be to
- A. Rinse the tooth in water before placing it in the socket
- B. Place the tooth in a clean plastic bag for transport to the dentist
- C. Hold the tooth by the roots until reaching the emergency room
- D. Ask the child to replace the tooth even if the bleeding continues
Correct Answer: A
Rationale: Rinse the tooth in water before placing it in the socket. Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in water, saline solution or milk before re-implantation. If possible, replace the tooth in its socket within 30 minutes, avoiding contact with the root.