Nokea
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.
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A client has been started on a monoamine oxidase inhibitor (MAOI). Which information should the nurse include when teaching the client about the medication?
- A. This medication can cause severe drowsiness.
- B. The client must avoid foods that contain tyramine.
- C. The medication is associated with a high rate of abuse.
- D. The medication will begin to alleviate symptoms of depression almost immediately.
Correct Answer: B
Rationale: MAOIs are used to treat depression. Although MAOIs usually produce hypotension as a side effect, potentially lethal hypertension can occur if the client eats foods that contain tyramine. Such foods include aged cheeses, hot dogs, and beer, among others. The medication does not cause drowsiness, is not associated with a high rate of abuse, and does not act almost immediately.
The nurse has taught a client with a below-the-knee amputation about home care and about monitoring for and preventing complications related to prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client stated that which action should be taken?
- A. Wear a clean nylon sock over the residual limb every day.
- B. Use a mirror to inspect all areas of the residual limb each day.
- C. Toughen the skin of the residual limb by rubbing it with alcohol.
- D. Prevent cracking of the skin of the residual limb by applying lotion daily.
Correct Answer: B
Rationale: The client should inspect all surfaces of the residual limb daily for irritation, blisters, and breakdown. The client should wear a clean woolen (not nylon) sock each day. The residual limb is cleansed daily with a gentle soap and water and dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils and creams are also avoided because they are too softening to the skin for safe prosthesis use.
The nurse monitors a client for brachial plexus compromise after shoulder arthroplasty and is checking the status of the ulnar nerve. Which technique should the nurse use to assess the status of this nerve?
- A. Ask the client to raise the forearm above the head.
- B. Have the client spread all of the fingers wide and resist pressure.
- C. Ask the client to move the thumb toward the palm and then back to the neutral position.
- D. Have the client grasp the nurse's hand, and note the strength of the client's first and second fingers.
Correct Answer: B
Rationale: So that the nurse may assess the ulnar nerve status, the client is asked to spread all of the fingers wide and resist pressure. Weakness against pressure may indicate compromise of the ulnar nerve. Raising the forearm above the head assesses the flexion of the biceps and determines the status of the cutaneous nerve. Moving the thumb toward the palm and back describes the assessment of the status of the radial nerve. Having the client grasp the nurse's hand and assessing the strength of the first 2 fingers describes the assessment of the status of the medial nerve.
A school nurse is performing screening examinations for scoliosis. Which signs of scoliosis should the nurse assess for? Select all that apply.
- A. Chest asymmetry
- B. Equal waist angles
- C. Unequal rib heights
- D. Equal rib prominences
- E. Equal shoulder heights
- F. Lateral deviation and rotation of each vertebra
Correct Answer: A,C,F
Rationale: Scoliosis is a lateral curvature of the spine. To ensure early detection and treatment, children aged 9 through 15 years should be screened for scoliosis; those at greatest risk are girls from 10 years of age through adolescence. The child should be unclothed or wearing only underpants so that the chest, back, and hips can be clearly seen. The child should stand with the weight equally on both feet, legs straight, and arms hanging loosely at the sides. The nurse then observes for the signs of scoliosis. These signs include nonpainful lateral curvature of the spine, a curve with one turn (C curve) or two compensating curves (S curve), lateral deviation and rotation of each vertebra, unequal shoulder heights, unequal waist angles, unequal rib prominences and chest asymmetry, and unequal rib heights.
The nurse is discussing concerns the parent has with his 3-year-old. The parent identifies limitations in the child's activities. Select all that should be of concern to the nurse.
- A. unable to work simple toys
- B. unable to understand simple instructions
- C. unable to say first and last name
- D. unable to name any colors or numbers
Correct Answer: A,B,D
Rationale: By age 3, children should manipulate simple toys, follow simple instructions, and name some colors or numbers. These limitations (A, B, D) suggest developmental delays requiring further evaluation. Saying first and last name (C) is less critical at this age.