Nokea
The nurse observes a client with dementia not recognizing their family member. The nurse understands that this client is demonstrating signs of which of the following?
- A. Apraxia
- B. Agraphia
- C. Agnosia
- D. Aphasia
Correct Answer: C
Rationale: Agnosia is the inability to recognize familiar objects or people, common in dementia.
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The nurse has received a prescription for a mannitol infusion. Which type of intravenous tubing should be used to administer mannitol?
- A. Microdrip
- B. Filtered
- C. Vented
- D. Non-vented
Correct Answer: B
Rationale: Mannitol is a hyperosmolar diuretic that can crystallize in IV tubing, potentially causing blockages. Filtered tubing is required to prevent crystals from entering the bloodstream, ensuring safe administration. Microdrip, vented, and non-vented tubing do not address this risk.
The nurse is performing a medication reconciliation for a client taking prescribed phenytoin. Which medication should the nurse question with the physician while the client is taking phenytoin?
- A. Thiamine
- B. Prazosin
- C. Warfarin
- D. Acyclovir
Correct Answer: C
Rationale: Phenytoin induces liver enzymes, which can decrease warfarin's effectiveness, increasing the risk of clotting. Thiamine, prazosin, and acyclovir have no significant interactions with phenytoin.
The nurse who is caring for a post-stroke client suddenly notes that the client has a fixed and dilated pupil. What would be the most appropriate action by the nurse?
- A. Reduce environmental stimuli.
- B. Reassess after ten minutes.
- C. Check the client's blood pressure.
- D. Notify the physician.
Correct Answer: D
Rationale: A fixed and dilated pupil suggests increased intracranial pressure, requiring immediate physician notification.
The nurse is caring for a client with Huntington's disease. Which of the following assessment findings would be expected?
- A. Halitosis
- B. Chorea
- C. Hallucinations
- D. Hematemesis
- E. Weight loss
Correct Answer: B,E
Rationale: Chorea (involuntary movements) and weight loss are hallmark symptoms of Huntington's disease.
This nurse is caring for a client who is receiving prescribed carbamazepine. Which of the following findings would indicate a therapeutic response?
- A. Decreased mood lability
- B. Steady gait
- C. Urinary continence
- D. Increased bone mass
Correct Answer: B
Rationale: Carbamazepine is an anticonvulsant used for seizures, and a steady gait indicates reduced seizure activity or improved neurological stability. Mood lability, urinary continence, and bone mass are not primary therapeutic outcomes.