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A client is going to be taking imipramine (Tofranil) at home following discharge.
The nurse should instruct the client to report which of the following immediately to the nurse?
- A. Sore throat, fever, increased fatigue, vomiting, diarrhea.
- B. Dry mouth, nasal stuffiness, weight gain.
- C. Rapid heartbeat, frequent headaches, yellowing of eyes or skin.
- D. Weakness, staggering gait, tremor, feeling of drunkenness.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-possible side effects of Tofranil, a tricyclic antidepressant medication, which can be resolved by altering the dosage or changing the medication (2) describes side effects of antidepressants, which client can learn to manage at home without changing the medication (3) describes side effects of a different category of medications (4) describes side effects of a different category of medications
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A client who has overdosed on a large quantity of diazepam (Valium).
Which of the following nursing actions should take priority during the first several days of this client's inpatient treatment?
- A. Complete a full psychiatric assessment.
- B. Get in touch with the client's family to involve them in treatment.
- C. Observe and record vital signs frequently, including neurological symptoms.
- D. Determine whether this client may need long-term therapy after this hospitalization.
Correct Answer: C
Rationale: Strategy: Think Maslow. (1) psychosocial, can be done after the client has been medically stabilized (2) psychosocial, can be done after the client has been medically stabilized (3) correct-physical, because of potentially life-threatening complications of depressant overdose such as respiratory failure, pulmonary edema, and seizures, nurse's priority is observation and documentation of vital signs (4) psychosocial, can be done after the client has been medically stabilized
A diabetic client has been maintained on Glucophage (metformin) for regulation of his blood glucose levels. Which teaching should be included in the plan of care?
- A. Report changes in urinary pattern.
- B. Allow six weeks for optimal effects.
- C. Increase the amount of carbohydrates in your diet.
- D. Use lotions to treat itching.
Correct Answer: A
Rationale: Metformin can affect kidney function, so changes in urinary patterns should be reported. Optimal effects occur sooner than six weeks , carbohydrates should be balanced, not increased , and itching is not a common side effect .
While monitoring the urine specific gravity of a client with a head injury, the nurse notes that the client's specific gravity is 1.004 . The most likely explanation for this finding is:
- A. The client is adequately hydrated.
- B. The client is experiencing renal failure.
- C. The client has adequate ADH secretion.
- D. The client is experiencing diabetes insipidus.
Correct Answer: D
Rationale: A low specific gravity (1.004) suggests dilute urine, common in diabetes insipidus due to impaired ADH secretion, often seen in head injuries.
The physician has ordered a low-magnesium diet for a client with end-stage renal failure. Which of the following diet selections should be removed from the client's meal tray?
- A. Fruit compote
- B. Spinach salad
- C. Baked potato
- D. Custard
Correct Answer: B
Rationale: Spinach is high in magnesium, which should be restricted in end-stage renal failure due to impaired excretion. Fruit compote , baked potato , and custard are lower in magnesium.
In addition to standard precautions, a nurse should implement contact precautions for which client?
- A. 60 year-old with herpes simplex
- B. 6 year-old with mononucleosis
- C. 45 year-old with pneumonia
- D. 3 year-old with scarlet fever
Correct Answer: A
Rationale: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.