Nokea
The nurse teaches a client scheduled for an I.V. pyelogram what to expect when the dye is injected. The nurse knows that the client has correctly understood what was taught when he states that he may experience which of the following sensations when the dye is injected?
- A. A metallic taste.
- B. Flushing of the face.
- C. Cold chills.
- D. Chest pain.
Correct Answer: B
Rationale: Flushing is a common sensation during I.V. pyelogram dye injection due to vasodilation caused by the contrast medium.
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A client with a history of breast cancer is prescribed anastrozole (Arimidex). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Anastrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.
The nurse is caring for a client with a diagnosis of Parkinson's disease who is taking benztropine mesylate daily. When assessing the client, what should the nurse specifically monitor for to determine if the client is experiencing a side effect of this medication?
- A. Pupil response
- B. Prothrombin time
- C. Skin temperature
- D. Intake and output
Correct Answer: D
Rationale: Urinary retention is a side effect of benztropine mesylate, an anticholinergic medication. The nurse needs to observe for dysuria, distended abdomen, voiding in small amounts, and overflow incontinence. The remaining options do not relate to this medication.
A client with a history of asthma is prescribed montelukast (Singulair). The nurse should explain that this medication works by:
- A. Dilating the bronchioles.
- B. Reducing airway inflammation.
- C. Thinning mucus secretions.
- D. Suppressing the cough reflex.
Correct Answer: B
Rationale: Montelukast, a leukotriene inhibitor, reduces airway inflammation in asthma, preventing symptoms.
On entering a toddler's room, the nurse finds the mother sitting about 8 feet from the child and watching television while the toddler is screaming. Which of the following is the most appropriate response by the nurse?
- A. What happened between you and your child?'
- B. Why is your child screaming?'
- C. Did something cause your child to be upset?'
- D. Have you tried to calm down your child?'
Correct Answer: C
Rationale: This response seeks to understand the situation without judgment, encouraging the mother to explain the toddler's distress.
The home care nurse is doing an assessment interview with an older adult client who asks the nurse to buy some groceries for her because she is not feeling well today. Which statement should the nurse use in response?
- A. Do you often need help with food shopping?
- B. Let's discuss how we can solve this problem.
- C. Do you have any support systems for shopping?
- D. I wish I could but I don't have time to run errands.
Correct Answer: B
Rationale: The nurse's duty is to help the client; but in helping the client, the nurse's first action is to finish the assessment and then find immediate and long-term solutions to the problem. In options 1 and 3 the nurse asks a closed-ended question, which is unlikely to further nurse-client communication. Option 4 is inappropriate while failing to address the client's problem.