Nokea
The nurse is talking with a client who has urge incontinence and is receiving tolterodine. It would require immediate follow-up if the client reports
- A. straining to have a bowel movement
- B. going an entire workday without needing to urinate
- C. using over-the-counter artificial saliva products for dry mouth
- D. experiencing occasional dizziness in the morning and with position changes
Correct Answer: B
Rationale: Not urinating for an entire workday suggests urinary retention, a serious side effect of tolterodine, requiring immediate evaluation to prevent bladder damage.
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The client has been vomiting for several days. Which blood gas values is he likely to have?
- A. pH=7.32; CO2=60; HCO3=30
- B. pH=7.32; CO2=33; HCO3=18
- C. pH=7.54; CO2=28; HCO3=22
- D. pH=7.54; CO2=32; HCO3=34
Correct Answer: C
Rationale: Prolonged vomiting causes metabolic alkalosis (high pH, low CO2) due to loss of stomach acid, matching pH=7.54, CO2=28, HCO3=22.
The nurse is screening clients with major depressive disorder for those at risk for suicide. The nurse should recognize the client at highest risk for suicide is the client with
- A. substance use disorder who is married and participates in community programs
- B. Parkinson disease who is divorced and has recently become unemployed
- C. breast cancer who is married and is newly diagnosed with alcohol use disorder
- D. type 2 diabetes mellitus who is recently divorced and has 3 children
Correct Answer: B
Rationale: Recent unemployment and divorce are significant stressors that increase suicide risk, especially in a client with a chronic condition like Parkinson disease, which can exacerbate depressive symptoms.
A 20-year-old woman is admitted to the hospital following an accident. Her uncle, a physician from out of state, visits her and asks to see her chart. How should the nurse respond?
- A. Comply with the request and give the chart to the physician
- B. Explain that written permission from his niece is needed first
- C. Suggest that he discuss the case with the attending physician
- D. Give him the chart but do not let him remove it from the nurse's station
Correct Answer: B
Rationale: HIPAA regulations require patient consent for chart access, even by a physician relative, unless they are directly involved in care. Permission from the patient is needed first.
A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?
- A. Change in body image
- B. An unfamiliar environment
- C. Perceived loss of control
- D. Guilt over being hospitalized
Correct Answer: C
Rationale: For school-age children, major fears are loss of control and separation from friends/peers.
A woman is scheduled for an electromyography procedure (EMG) in the outpatient department. What should the nurse say to the woman?
- A. Do not eat or drink anything after midnight the night before the procedure.'
- B. Are you allergic to shellfish or iodine?'
- C. Do not eat or drink anything that contains caffeine for two to three days before the procedure.'
- D. There is no special preparation for this procedure.'
Correct Answer: D
Rationale: EMG requires no special preparation, as it involves muscle and nerve testing without fasting, allergies, or caffeine restrictions.