Nokea
The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following instructions should the nurse include?
- A. Take the medication daily to prevent migraines.
- B. Report any chest pain.
- C. Stop the medication if headaches decrease.
- D. Avoid regular neurological exams.
Correct Answer: B
Rationale: Chest pain may indicate vasoconstriction, a serious sumatriptan side effect. Options A, C, and D are incorrect.
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The nurse is caring for a client with asthma who has developed gastroesophageal reflux disease (GERD). Which of the following medications prescribed for the client may aggravate GERD?
- A. Anticholinergics
- B. Corticosteroids
- C. Histamine blocker
- D. Antibiotics
Correct Answer: A
Rationale: An anticholinergic medication will decrease gastric emptying and the pressure on the lower esophageal sphincter.
The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Dry mouth.
- B. Mild sedation.
- C. Muscle stiffness and tremors.
- D. Insomnia.
Correct Answer: C
Rationale: Muscle stiffness and tremors suggest extrapyramidal symptoms, a serious haloperidol side effect. Options A, B, and D are less urgent.
The nurse is performing in-service education about the use of the defibrillator.
Which of the following statements, if made by the nurse, is MOST important?
- A. Do not touch the bed when using the defibrillator.
- B. Check the defibrillator every 24 hours.
- C. Do not leave the defibrillator plugged in.
- D. Do not place the paddles over the electrodes.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-is a priority to prevent accidental countershock (2) equipment should be checked every eight hours (3) equipment should remain plugged in at all times (4) is not a priority; while this should not occur, it can be safely done
The nurse is evaluating the progress of a client who has had a cerebrovascular accident and realizes there has been limited progress. What should the nurse do?
- A. Transfer the client to another caregiver
- B. Reassess the goals with the client
- C. Request a longer hospital stay
- D. Role play the current plan with the client
Correct Answer: B
Rationale: Reassessing goals adjusts the care plan to the client's current abilities, optimizing recovery post-CVA.
The nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse?
- A. 1 in 4 chance for each child to carry that trait
- B. 1 in 4 risk for each child to have the disease
- C. 1 in 2 chance of avoiding the trait and disease
- D. 1 in 2 chance that each child will have the disease
Correct Answer: B
Rationale: 1 in 4 risk for each child to have the disease. Cystic fibrosis is autosomal recessive, with a 25% chance of the disease per pregnancy if both parents are carriers.