Nokea
The nurse is teaching the parent of the 3-year-old being treated with vincristine sulfate for Wilms' tumor. The nurse should inform the parents to immediately notify the HCP of which most significant adverse effect?
- A. The child develops diarrhea.
- B. The child's hair begins to fall out.
- C. The child develops dysphagia and paresthesia.
- D. The child has signs or symptoms of depression.
Correct Answer: C
Rationale: A: Both diarrhea and severe constipation are adverse effects of vincristine, and prophylactic treatment is implemented at the beginning of therapy to decrease the potential of these occurring. B: Hair loss is a common adverse reaction to the medication and is reversible. C: Dysphagia and paresthesia are CNS adverse effects from vincristine sulfate (Oncovin). The nurse should teach the parent to notify the HCP immediately if these occur. D: Three-year-olds may not show signs or symptoms of depression. If present, the signs and symptoms should be distinguished as being associated with the neoplastic disease itself or as side effects of the medication.
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The client taking paroxetine telephones the mental health clinic nurse and states, “Since I started taking St. John's wort, I have had a high fever and muscle stiffness, and I am sweating a lot.†Which statement is most appropriate?
- A. You may have the flu; call your primary provider to make an appointment.
- B. Take ibuprofen, drink fluids, and rest; call tomorrow if the symptoms worsen.
- C. Could you have doubled up on your medication, taking more than prescribed?
- D. You should be taken to the emergency department right away to be evaluated.
Correct Answer: D
Rationale: Fever, muscle stiffness (rigidity), and diaphoresis are symptoms of serotonin syndrome, a potentially fatal condition that may occur with concurrent use of St. John's wort and paroxetine (Paxil). The client should be taken to the ED.
A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur?
- A. hyperkalemia
- B. hypernatremia
- C. hypokalemia
- D. hypomagnesemia
Correct Answer: C
Rationale: Furosemide, a diuretic, commonly causes potassium loss, leading to hypokalemia, which can potentiate digitalis toxicity, requiring close monitoring.
The nurse is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?
- A. I am nervous about how painful labor will be.
- B. I need to review my finances and make sure I am prepared to care for a child.
- C. I hate this nausea that I've been having for a week.
- D. I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent.
Correct Answer: D
Rationale: The nurse should follow up on the client's lack of support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea.
You are caring for a 78-year-old woman who is wondering why she was diagnosed with glaucoma. Although she has several risk factors, which of these is not one of them?
- A. age
- B. blood pressure reading of 143/89
- C. Mexican-American heritage
- D. 20/80 vision
Correct Answer: D
Rationale: Age over 60 and Mexican-American ancestry are both risk factors for glaucoma. Elevated blood pressure also is a risk factor as it can cause optic nerve damage. 20/80 vision, while poor, is not a causal factor for glaucoma.
The child, admitted to the ED, is experiencing nausea and vomiting, salivation, respiratory muscle weakness, and depressed reflexes an hour after exposure to pesticides. Which medications should the nurse anticipate administering to the child?
- A. Atropine and flumazenil
- B. Atropine and pralidoxime
- C. Epinephrine and naloxone
- D. Epinephrine and digoxin immune Fab
Correct Answer: B
Rationale: A: Flumazenil (Romazicon) antagonizes the effects of benzodiazepines on the CNS, such as sedation, impaired recall, and psychomotor impairment. B: An organophosphate base in pesticides causes acetylcholine to accumulate at neuromuscular junctions. Atropine (Atropine), an anticholinergic medication, and pralidoxime chloride (Protopam), a cholinesterase reactivator, are effective antidotes to reverse the symptoms. C: Epinephrine (EpiPen) is an alpha- and beta-adrenergic agonist and cardiac stimulant that strengthens myocardial contractions, increases systolic BP, increases cardiac rate and output, and constricts bronchial arterioles, inhibiting histamine release. Naloxone (Narcan) is a narcotic antagonist that reverses the effects of opiates. D: Digoxin immune Fab (Digibind) is the antidote for digoxin and digitoxin, which acts by complexing with circulating digoxin or digitoxin, preventing the drug from binding at receptor sites.