Nokea
The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis, he can expect to find:
- A. Irregular movement of the wrist
- B. Enlargement of the breasts
- C. Dilated veins around the umbilicus
- D. Redness of the palmar surfaces
Correct Answer: A
Rationale: Asterixis, a flapping tremor of the wrists when extended, is a sign of hepatic encephalopathy in cirrhosis due to ammonia buildup. The other findings are unrelated to asterixis.
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A client with AIDS tells the nurse that he has been using herbal supplements in addition to the regimen of drugs prescribed by the physician. The nurse should tell the client that:
- A. Most herbals are well suited to use with prescription medications.
- B. He should buy only FDA-approved herbal supplements for use.
- C. The use of herbals may alter the effect of the medication he is taking.
- D. The herbal supplements should be taken at the same time as his medication.
Correct Answer: C
Rationale: Herbal supplements can interact with antiretroviral drugs, altering their efficacy or toxicity (e.g., St. John’s wort reduces protease inhibitor levels). The nurse should advise the client to discuss herbals with the physician, as they are not inherently safe or FDA-regulated for this purpose.
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking 'the blue pill' (haloperidol) in the morning and evening, and 'the white pill' (benztropine) right before bedtime. The nurse might suggest to the client that she try:
- A. Doubling the daily dose of benztropine
- B. Decreasing the haloperidol dosage for a few days
- C. Taking the benztropine in the morning
- D. Taking her medication with food or milk
Correct Answer: C
Rationale: Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. This response is an appropriate independent nursing action. Because motor restlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.
The nurse is caring for a client with a history of Raynaud’s disease. The nurse should expect the client to have:
- A. Color changes in fingers
- B. Joint swelling
- C. Fever
- D. Chest pain
Correct Answer: A
Rationale: Raynaud’s disease causes vasospasms, leading to color changes (white, blue, red) in the fingers triggered by cold or stress.
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for cesarean delivery
- D. Administer tocolytics
Correct Answer: A
Rationale: Postpartum endometritis is treated with antibiotics to address the uterine infection. Fetal heart tones are irrelevant postpartum cesarean delivery is not indicated and tocolytics are for preterm labor.
When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:
- A. Fruit juices
- B. Diluted carbonated drinks
- C. Soy-based, lactose-free formula
- D. Regular formulas mixed with electrolyte solutions
Correct Answer: C
Rationale: Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea. Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhea. Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. Regular formulas contain lactose, which can increase diarrhea.