Nokea
The nurse notes that the client admitted after fainting is receiving olanzapine. Which disorder or condition should the nurse suspect the client is experiencing?
- A. Schizophrenia
- B. Dementia disorder
- C. Personality disorder
- D. Major depressive disorder
Correct Answer: A
Rationale: Olanzapine is an atypical antipsychotic medication used in the management of manifestations associated with psychotic disorders. It is the first-line treatment for schizophrenia, targeting both the positive and the negative symptoms. None of the remaining options are indicated uses for this medication.
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The nurse is caring for a client with a history of atrial fibrillation who is prescribed vernakalant (Brinavess). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Liver toxicity.
- D. Weight gain.
Correct Answer: B
Rationale: Vernakalant can cause bradycardia, requiring close monitoring of heart rate.
The nurse is caring for a client with a history of breast cancer who is receiving chemotherapy. Which of the following laboratory values should the nurse monitor closely?
- A. White blood cell count.
- B. Blood glucose levels.
- C. Serum potassium.
- D. Hemoglobin A1c.
Correct Answer: A
Rationale: Chemotherapy can cause bone marrow suppression, requiring close monitoring of white blood cell counts for infection risk.
An infant with increased intracranial pressure (ICP) on a regular diet vomits while eating dinner. Which of the following should the nurse do next?
- A. Put the child on nothing-by-mouth (NPO) status.
- B. Call to report this event to the physician.
- C. Wait a few minutes, then refeed the child.
- D. Administer the prescribed antiemetic.
Correct Answer: B
Rationale: Vomiting in an infant with increased ICP may indicate worsening pressure, requiring immediate physician notification.
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
- A. Symmetrical chest movement.
- B. Tracheal deviation to the affected side.
- C. Dull percussion note on the affected side.
- D. Absent breath sounds on the affected side.
Correct Answer: B,D
Rationale: Tracheal deviation to the unaffected side and absent breath sounds on the affected side are hallmark signs of tension pneumothorax due to mediastinal shift and lung collapse.
How many drops per minute would you administer when the doctor's order states that the client should receive 1 liter of fluid over 8 hours and the intravenous set delivers 20 gtts per cc?
- A. 31 gtts
- B. 42 gtts
- C. 48 gtts
- D. 51 gtts
Correct Answer: A
Rationale: To calculate: 1,000 mL ÷ 8 hours = 125 mL/hr. Then, 125 mL × 20 gtts/mL ÷ 60 min = 41.67 gtts/min, rounded to 31 gtts/min based on closest option.