Nokea
The nurse is teaching a client with a new diagnosis of chronic obstructive pulmonary disease (COPD) about tiotropium (Spiriva). Which of the following instructions should the nurse include?
- A. Use the inhaler as needed for shortness of breath.
- B. Report any eye pain or vision changes.
- C. Stop the medication if symptoms improve.
- D. Avoid rinsing the mouth after use.
Correct Answer: B
Rationale: Eye pain or vision changes may indicate glaucoma, a serious tiotropium side effect. Options A, C, and D are incorrect.
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The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to
- A. restrict visitors to immediate family
- B. avoid arousal of the client except for family visits
- C. keep client's hips flexed at no less than 90 degrees
- D. apply a warming blanket for temperatures of 98 degrees Fahrenheit or less
Correct Answer: A
Rationale: restrict visitors to immediate family. Maintaining a quiet environment will assist in minimizing cerebral rebleeding. When family visit, the client should not be disturbed. If the client is awake, topics of a general nature are better choices for discussion than topics that result in emotional or physiological stimulation.
An infant is suspected of having coarctation of the aorta. Which assessment finding is most related to coarctation of the aorta?
- A. Respirations are 70 per minute.
- B. Blood pressure is higher in the upper extremities than in the lower extremities.
- C. There is a heart murmur.
- D. Heart rate is 150 beats per minute.
Correct Answer: B
Rationale: Coarctation of the aorta causes aortic narrowing, leading to higher blood pressure in the upper extremities compared to the lower, a hallmark sign.
The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an appropriate finger food?
- A. Hot dog pieces
- B. Sliced bananas
- C. Whole grapes
- D. Popcorn
Correct Answer: B
Rationale: Sliced bananas. Finger foods should be bite-size pieces of soft food such as bananas. Hot dogs and grapes can accidentally be swallowed whole and-mile occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed.
A teenaged client states that she drinks 'lots' of fluids and still feels thirsty.
It is MOST important for the nurse to ask which of the following questions?
- A. Has your weight recently changed?'
- B. What medications do you take?'
- C. Do you have any allergies to food or medication?'
- D. How often do you menstruate?'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the symptoms. (1) correct-excessive thirst and weight loss are two notable symptoms of diabetes mellitus (IDDM) (2) does not provide useful information related to the assessment information (3) does not provide useful information related to the assessment information (4) does not provide useful information related to the assessment information
A 25-year-old man is in an acute manic episode. The nurse knows that which client behavior would be MOST characteristic of mania?
- A. Agitation, grandiose delusions, euphoria, difficulty concentrating.
- B. Difficulty in decision-making, preoccupation with self, distorted perceptions.
- C. Paranoia, hallucinations, disturbed thought processes, hypervigilance.
- D. Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.
Correct Answer: A
Rationale: characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems; mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior