Nokea
The nurse is working in a high risk antepartum clinic. A 40 year-old woman in the first trimester gives a thorough health history. Which information should receive priority attention by the nurse?
- A. Her father and brother are insulin-dependent diabetics
- B. She has taken 800 mcg of folic acid daily for the past year
- C. Her husband was treated for tuberculosis as a child
- D. She reports recent use of over-the-counter sinus remedies
Correct Answer: D
Rationale: Over-the-counter drugs are a possible danger in early pregnancy. A report by the client that she has taken medications should be followed up immediately.
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The client who's developing signs and symptoms indicate hyperglycemia?
- A. Polydipsia, polyuria, and weight loss.
- B. Weight gain, tiredness, and bradycardia.
- C. Irritability, diaphoresis, and tachycardia.
- D. Diarrhea, abdominal pain, and weight loss.
Correct Answer: A
Rationale: Hyperglycemia causes polydipsia, polyuria, and weight loss due to osmotic diuresis.
A 12-year-old boy injured his right knee yesterday during a soccer game. He is brought to the outpatient clinic by his mother. His right knee is painful, swollen, and bruised. During the interview, the nurse learns that the boy has hemophilia A. Which of the following medications would be BEST for this patient?
- A. Oxycodone terephthalate (Percodan).
- B. Ibuprofen (Motrin).
- C. Enteric-coated aspirin.
- D. Codeine phosphate (Paveral).
Correct Answer: D
Rationale: Hemophilia A increases bleeding risk, so medications like Percodan (A, contains aspirin), ibuprofen (B), and aspirin (C) are contraindicated as they impair clotting. Codeine (D) is a safe analgesic for moderate to severe pain in this population.
An adult is on long-term aspirin therapy and complains of tinnitus. Which interpretation by the nurse is accurate?
- A. The aspirin is working as expected.
- B. The client ingested more medication than was recommended.
- C. The client has an upper GI bleed.
- D. The client is experiencing a minor overdose.
Correct Answer: D
Rationale: Tinnitus is a sign of aspirin toxicity (salicylism), indicating a minor overdose. It's not an expected effect, and GI bleed would present with other symptoms like melena.
The family of a young adult who has been declared brain dead following an auto accident is approached by the physician about organ donation. Later they ask the nurse, 'If we donate the organs, can we still have a viewing and a regular funeral?' How should the nurse respond?
- A. Yes. The surgery to donate the organs will not deface the body of your loved one.'
- B. You can have a normal funeral, but you may want a closed casket because of the injuries from the accident.'
- C. The surgery to take the organs will make it impossible to have an open casket for the viewing.'
- D. Some clergy do not want to perform funerals for those whose organs have been removed. You should check with your clergyperson.'
Correct Answer: A
Rationale: Organ donation surgery is performed carefully to preserve the body's appearance, allowing open-casket viewing and normal funeral proceedings, independent of accident injuries or clergy views.
A client scheduled for a fluorescein angiography is to have mydriatic eye drops instilled in both eyes 1 hour prior to the test. The nurse knows that the purpose of the medication is:
- A. To anesthetize the cornea
- B. To dilate the pupils
- C. To constrict the pupils
- D. To paralyze the muscles of accommodation
Correct Answer: B
Rationale: Mydriatic drops dilate pupils, allowing better visualization of the retina during fluorescein angiography.