Nokea
The nursing staff has safely and successfully secluded and restrained a client with acute mania who discussed the nurse and threw a chair against the wall in the community room. Which statement by the nurse is most helpful to the client at this time?
- A. Threatening others and throwing furniture is not allowed.'
- B. You have been restrained until you can manage your behavior.'
- C. Since you have been here before, you know what the rules are.'
- D. We are only doing this for your own good, so calm down.'
Correct Answer: B
Rationale: Explaining the reason for restraint (to ensure safety until behavior is managed) is therapeutic, clear, and nonjudgmental, helping the client understand the intervention.
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Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
- A. Polyuria, nausea, and severe headaches
- B. Polydipsia, translucent skin, and obesity
- C. Fever, tachycardia, and systolic hypertension
- D. Profuse diaphoresis, flushing, and constipation
Correct Answer: C
Rationale: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after inhalation.
- C. Take the inhaler with meals.
- D. Stop the inhaler if dizziness occurs.
Correct Answer: B
Rationale: Rinsing the mouth after tiotropium inhalation prevents oral thrush.
A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Nausea.
- B. Gingival hyperplasia.
- C. Rash.
- D. Drowsiness.
Correct Answer: C
Rationale: A rash may indicate a serious hypersensitivity reaction to phenytoin, such as Stevens-Johnson syndrome, requiring immediate reporting.
When a client states that he is allergic to amoxicillin (Ampicillin) even though his medication administration record and armband do not indicate medication allergies, the nurse should:
- A. Administer the prescribed medication.
- B. Withhold the amoxicillin (Ampicillin).
- C. Administer another, similarly acting antibiotic.
- D. Call the family to verify the client's statement.
Correct Answer: B
Rationale: Withholding the medication is the safest action until the allergy can be verified to prevent an allergic reaction.
A client with a diagnosis of bipolar disorder is prescribed lithium. The nurse should monitor the client for which of the following early signs of toxicity?
- A. Tremors.
- B. Weight loss.
- C. Increased appetite.
- D. Dry skin.
Correct Answer: A
Rationale: Tremors are an early sign of lithium toxicity, requiring prompt monitoring and potential dose adjustment.