Nokea
A client presents with confusion, mood lability, impaired communication, and lethargy.
The nurse should question which of the following orders?
- A. Dexamethasone suppression Test .
- B. Thyroid studies.
- C. Drug toxicology screen.
- D. Trendelenburg Test .
Correct Answer: D
Rationale: Strategy: Think about each Test . (1) may be ordered to determine the presence of major depression (2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made (3) may be ordered to see if the client's symptoms are caused by excessive use of medications or alcohol (4) correct-Test is used with a client who may have varicose veins, no relationship to the symptoms described in this situation
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A client has been taking propranolol (Inderal) 40 mg bid and furosemide (Lasix) 40 mg qd for several months. Two weeks ago, the physician added verapamil (Calan) 80 mg tid to his medication regimen.
It is MOST important for the nurse to assess for which of the following?
- A. Tachycardia.
- B. Diarrhea.
- C. Peripheral edema.
- D. Impotence.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to medication. (1) will cause bradycardia (2) usually causes constipation (3) correct-Calan is a calcium-channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries, when used with other antihypertensives can cause hypotension and heart failure (4) not most important or frequent side effect
A client after right cataract surgery.
The nurse would intervene in which of the following situations?
- A. Client is in the supine position.
- B. The head of the bed is elevated 30°.
- C. The client is lying on her right side.
- D. An eye shield is over the right eye.
Correct Answer: C
Rationale: Strategy: 'Nurse would intervene' indicates an incorrect action. (1) appropriate position (2) decreases swelling and pain (3) correct-client should not be positioned with operative side in a dependent position or against the bed (4) shield is appropriate
The nurse is teaching a client with a new diagnosis of epilepsy about valproic acid (Depakote). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any bruising or bleeding.
- C. Stop the medication if seizures decrease.
- D. Avoid regular liver function Test s.
Correct Answer: B
Rationale: Valproic acid can cause thrombocytopenia; reporting bruising or bleeding is critical. Options A, C, and D are incorrect or unsafe.
The nurse is caring for a client who is postoperative day 1 after a cholecystectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site
- B. Temperature of 100.8°F (38.2°C)
- C. Bile-colored drainage from the T-tube
- D. Urine output of 40 mL/hour
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-cholecystectomy complication. Options A, C, and D are normal: pain is expected, bile drainage is typical, and urine output is adequate.
A husband and wife meet at the mental health clinic to make an appointment for family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the husband says, 'I guess we just don't get along.' Which of the following responses by the nurse is MOST appropriate?
- A. Your wife seems to be upset by the situation.
- B. Perhaps you should both go home now.
- C. Try to think about what precipitated her crying.
- D. The situation is difficult for both of you.
Correct Answer: D
Rationale: Acknowledging the emotional impact on both spouses fosters therapeutic communication without judgment. Options A, B, and C are less effective: A focuses only on the wife, B dismisses the situation, and C may provoke defensiveness.