Nokea
The nurse is talking with a client who was stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?
- A. Hives
- B. Itching
- C. Airway obstruction
- D. Diarrhea
Correct Answer: C
Rationale: Injectants, such as bee venom, and some other allergens can produce systemic and potentially fatal effects, including shock and airway obstruction caused by laryngeal swelling. Although all other answers can occur with an allergen, they are not the most serious complication.
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A client is taking the immunosuppressant medication, azathioprine (Imuran), for the treatment of Crohn's disease. What statement made by the client demonstrates an understanding of the side effects of this medication?
- A. I will notify the doctor if I have a fever or any other signs of infection.'
- B. I will drink at least 3 L of fluid per day.'
- C. I will notify the doctor if I am not having a bowel movement daily.'
- D. I will stop taking my medication if I notice any side effects and then notify the doctor.'
Correct Answer: A
Rationale: The client should be instructed to be sure to report any signs of infection since this drug suppresses the immune system and makes the client susceptible to infections. It is important for a client to drink 3 L of fluid when taking the immunosuppressant drug cyclosporine to prevent hemorrhagic cystitis, but this is not necessary for azathioprine. It is not necessary to inform the physician if the client is not having a bowel movement daily. The client should not stop taking the medication for any reason unless discussed with the physician.
The nurse is interviewing a client being admitted to the hospital and inquires about any allergies the client has. The client reports being allergic to aspirin and penicillin. What intervention should the nurse provide immediately to prevent complications related to allergies?
- A. Apply an allergy bracelet and flag the chart.
- B. Tape an EpiPen to the head of the bed.
- C. Inform the client not to take any medications with those substances in them.
- D. Call the physician.
Correct Answer: A
Rationale: The nurse asks each client about the existence of any allergies. If any are reported, the nurse flags the medical record and applies a wristband with the appropriate information. Throughout the client's care, the nurse observes for signs of an allergic reaction, especially when administering medication, applying substances such as tape or adhesive patches to the skin. Medication should never be left in the client's room. The responsibility for medications with the identified allergens lies with the healthcare personnel in the acute care facility. The physician does not need to be called if the chart is flagged.
The nurse has four clients who are scheduled to see the physician for 'fatigue' and other general symptom complaints. Which client does the nurse determine is at most risk for having chronic fatigue syndrome?
- A. Male of Hispanic descent, age 28 years
- B. Female of Caucasian descent, age 47 years
- C. Female of African descent, age 42 years
- D. Female of Chinese descent, age 18 years
Correct Answer: B
Rationale: Estimates are that as many as 4 million people in the United States have symptoms corresponding with chronic fatigue syndrome, but fewer than 80% have been diagnosed by a medical provider. Most clients who seek treatment for their symptoms are Caucasian women 40 to 59 years of age. CFS also occurs at lower rates among children, adolescents, and men.
The clinic nurse is caring for a client with an allergic disorder who has received the first sensitizing dose of a new drug. What nursing action is most important at this point?
- A. Assess the client for reduced urine output.
- B. Monitor the client for reactions.
- C. Assess the client for reduced appetite.
- D. Monitor the client for increased heart rate.
Correct Answer: B
Rationale: Monitoring the client for 30 minutes after desensitization injection is necessary to assess for allergic symptoms. Although it is important to ensure the client's comfort, it is not essential to assess the client for changes in urine output, appetite, or heart rate.
A client sustained an injury in one eye during a basketball game after being hit with another player's elbow. The client reports now having difficulty with vision in the other eye too, although that eye was not hit by the elbow. What does the nurse understand this phenomenon to be known as?
- A. Cataracts
- B. Psychosomatic blindness
- C. Glaucoma
- D. Sympathetic uveitis
Correct Answer: D
Rationale: When a person experiences trauma followed by inflammation to the iris, ciliary body, and choroid layer of one eye, the vision in the untraumatized eye also becomes affected. The term for this phenomenon is sympathetic uveitis. Cataracts do not occur from trauma, they develop over time. Psychosomatic blindness does not relate to the client's visual disturbance because the client is not blind at this time. Glaucoma is an eye disorder that occurs over time and is not related to trauma to the eye.