Nokea
The nurse understands that which of the ff. is a side effect most likely to be reported by patients receiving enalapril maleate (Vasotec)?
- A. Acne
- B. Diarrhea
- C. Cough
- D. Heartburn
Correct Answer: C
Rationale: The correct answer is C: Cough. Enalapril is an ACE inhibitor, and a common side effect is a dry, persistent cough due to the accumulation of bradykinin. This is a distinctive side effect of ACE inhibitors and should be reported to the healthcare provider. Acne (A), diarrhea (B), and heartburn (D) are not commonly associated with enalapril use and are less likely side effects.
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The nurse is reviewing the medication history of a new preoperative patient who is nil by mouth (NPO). The nurse notes that the patient has been on long-term oral steroid therapy. The nurse understands that which of the following is the reason that steroids cannot be abruptly stopped?
- A. Higher steroid levels are needed during
- B. Malignant hypertension will occur.
- C. Respiratory failure will result.
- D. Malignant hyperthermia will result.
Correct Answer: A
Rationale: The correct answer is A because abruptly stopping steroids can lead to adrenal insufficiency due to suppression of the adrenal glands. This can result in a sudden drop in cortisol levels, which are essential for various physiological functions. Patients on long-term steroid therapy need a gradual taper to allow the adrenal glands to resume cortisol production. Choices B, C, and D are incorrect as they do not directly relate to the physiological effects of stopping steroids abruptly.
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
- A. of the last dressing change and notices old and new drainage. The nurse administers pain medicine due at 1700 at 1600 because the patient reports
- B. increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of potassium when a
- C. patient reports leg cramps.
- D. The nurse elevates a leg cast when the patient reports decreased mobility.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in nursing clinical decision-making. In this scenario, the nurse considers the patient's self-reported information (time of last dressing change and observation of old and new drainage) as key data points to validate the need for changing the wound dressing. This aligns with the principles of evidence-based practice and ensures that the decision is based on accurate and relevant information.
Choices B, C, and D are incorrect because they do not involve the systematic validation of data to inform the nursing decision-making process. Choice B relies on family input rather than objective data, Choice C jumps to a treatment decision without confirming the underlying cause, and Choice D does not involve validating the patient's reported symptom before taking action.
The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
- A. Allow the client to grasp the nurses hand firmly
- B. Check the patient’s sensitivity to heat, cold, touch, and pain.
- C. Ask the client to pick up small and large objects between the thumb and forefinger
- D. Ask questions that require cognition and logic
Correct Answer: A
Rationale: Step-by-step rationale:
1. Allowing the client to grasp the nurse's hand firmly assesses grip strength and motor coordination.
2. This step helps evaluate the client's ability to follow instructions and perform a coordinated motor task accurately.
3. Assessing grip strength is essential in determining any muscle weakness or neurological deficits.
4. It also provides insight into the client's motor function and coordination abilities.
Summary:
- Choice B is incorrect because it focuses on sensory functions rather than motor functions.
- Choice C assesses fine motor skills, not grip strength and coordination.
- Choice D evaluates cognition and logic, which are not directly related to motor function assessment.
When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?
- A. Restricting fluids
- B. Forcing fluids
- C. Restricting sodium
- D. Restricting potassium
Correct Answer: C
Rationale: The correct answer is C: Restricting sodium. In hyperparathyroidism, there is an excess of parathyroid hormone leading to increased calcium levels. Sodium can worsen calcium excretion, exacerbating the condition. Restricting sodium can help reduce calcium loss.
A: Restricting fluids is not necessary unless the client has kidney issues.
B: Forcing fluids may not be beneficial and can lead to fluid overload.
D: Restricting potassium is not typically necessary unless the client has kidney issues.
The nurse will assess a loss of ability in which of the following areas?
- A. Balance
- B. Speech
- C. Judgment
- D. Endurance
Correct Answer: A
Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.