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The nurse provides instructions to the client taking clorazepate for the management of an anxiety disorder. What information related to this medication should the nurse provide to the client?
- A. Dizziness is a side effect.
- B. Smoking increases the effectiveness of the medication.
- C. If drowsiness occurs, call the primary health care provider.
- D. If gastrointestinal disturbances occur, discontinue the medication.
Correct Answer: A
Rationale: Dizziness is a common side effect of clorazepate, and clients should be instructed to change positions slowly to manage it. Smoking reduces the medication's effectiveness, drowsiness is expected and does not require contacting the provider, and gastrointestinal disturbances should be managed by taking the medication with food, not discontinuing it.
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The clinic nurse instructs a client diagnosed with diabetes mellitus about preventing diabetic ketoacidosis on days when the client is feeling ill. Which statement by the client indicates the need for further teaching?
- A. I need to stop my insulin if I am vomiting.
- B. I need to call my doctor if I am ill for more than 24 hours.
- C. I need to eat 10 to 15 g of carbohydrates every 1 to 2 hours.
- D. I need to drink small quantities of fluid every 15 to 30 minutes.
Correct Answer: A
Rationale: Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. The client needs to be instructed to continue taking insulin, even if vomiting and unable to eat, to prevent ketoacidosis. It is important to self-monitor blood glucose more frequently during illness (every 2 to 4 hours). If the premeal blood glucose is more than 250 mg/dL, the client should test for urine ketones and contact the primary health care provider. Calling the doctor if ill for more than 24 hours, consuming 10 to 15 g of carbohydrates every 1 to 2 hours, and drinking small quantities of fluid every 15 to 30 minutes are accurate interventions to maintain hydration and glucose control during illness.
A client is being monitored for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?
- A. Massaging the reddened areas
- B. Performing range of motion exercises
- C. Administering antithrombotics as ordered
- D. Feeding the client a high-carbohydrate diet
Correct Answer: B
Rationale: For a client at risk of impaired skin integrity due to decreased tissue perfusion, improving mobility is crucial to enhance tissue perfusion and prevent skin breakdown. Range of motion exercises are beneficial to increase circulation and prevent complications. Massaging reddened areas may further damage fragile skin. Administering antithrombotics may be necessary for specific conditions but does not directly address tissue perfusion. Feeding a high-carbohydrate diet does not directly improve tissue perfusion in this context.
The nurse should tell the client to avoid which item while taking phenelzine sulfate?
- A. Blueberries
- B. Vasodilators
- C. Aged cheeses
- D. Digitalis preparations
Correct Answer: C
Rationale: Phenelzine sulfate is in the monoamine oxidase inhibitor (MAOI) class of antidepressant medications. An individual taking an MAOI must avoid aged cheeses, alcoholic beverages, avocados, bananas, and caffeine drinks. There are also other food items to avoid, including chocolate, meat tenderizers, pickled herring, raisins, sour cream, yogurt, and soy sauce. Medications that should be avoided include amphetamines, antiasthmatics, and certain antidepressants. The client should also avoid vasoconstrictors because their concurrent use can cause hypertensive crisis.
The nurse has given instructions to the client diagnosed with chronic kidney disease about reducing pruritus from uremia. The nurse determines that the client needs further teaching if the client states the intention to use which item for skin care?
- A. Mild soap
- B. Oil in the bath water
- C. Lanolin-based lotion
- D. Alcohol cleansing pads
Correct Answer: D
Rationale: Alcohol cleansing pads increase skin dryness and pruritus in chronic kidney disease clients with uremia. Mild soap, bath oils, and lanolin-based lotions help reduce dryness and irritation without exacerbating symptoms.
The nurse provides home care instructions to a client diagnosed with cancer who has an implanted vascular access port. Which statement by the client indicates the need for further teaching?
- A. I should keep the site clean and dry.
- B. If the site becomes red, I will notify my doctor.
- C. I should pump the port daily to maintain patency.
- D. The port will need to be flushed with saline to maintain patency.
Correct Answer: C
Rationale: Implanted vascular access ports do not require daily pumping to maintain patency; this is incorrect. Keeping the site clean and dry, notifying the doctor about redness, and flushing with saline (or heparin, per agency protocol) are correct care measures.