Nokea
The school-aged child taking guanfacine for treating ADHD is being seen by the nurse at school. The child is pale, diaphoretic, and feeling dizzy. What should the nurse do first?
- A. Take the child's blood pressure
- B. Obtain a capillary glucose level
- C. Telephone the parent about the child
- D. Put a cool cloth on the child's forehead
Correct Answer: A
Rationale: Guanfacine (Tenex) can cause hypotension, making blood pressure the first assessment priority.
You may also like to solve these questions
The nurse is evaluating the effectiveness of lispro and glargine insulins being administered to the 2-year-old with type 1 DM. Which findings on the serum laboratory report indicate that treatment is effective?
- A. Blood glucose
- B. Hgb A1c
- C. Creatinine
- D. WBCs
Correct Answer: A, B
Rationale: The treatment goal for children with type 1 DM is blood glucose levels within the normal range (60-105 mg/dL for a 2-year-old). Hgb A1c levels are indicative of the average blood glucose levels over the past 2 to 3 months; normal A1c is 3.9% to 7.7%. Although the other laboratory values are normal, these do not indicate the effectiveness of insulin therapy.
The 9-year-old with SLE is receiving large doses of prednisolone. Which laboratory finding should the nurse recognize as an untoward effect of the medication?
- A. Total bilirubin of 4 mg/dL
- B. WBC count of 18,000/mm3
- C. Serum sodium of 130 mEq/L
- D. Random glucose of 130 mg/dL
Correct Answer: B
Rationale: A: The liver is not affected by prednisolone use, so an increased total bilirubin of 4 mg/dL is not related to the use of the drug. Normal total bilirubin in a 9-year-old should be less than 2 mg/dL. B: A WBC count of 18,000/mm3 may indicate an infection, an untoward effect of prednisolone (Omnipred). Prednisolone, a corticosteroid used to reduce inflammation, may increase the risk of infection. The normal WBC in a 9-year-old is 4500-11,100/mm3. C: Prednisolone has been associated with the adverse effect of hypokalemia, but not hyponatremia. Normal serum sodium is 135-145 mEq/L. D: Although corticosteroids may have the effect of increasing blood glucose, a random glucose of 130 mg/dL is not abnormal.
The LPN is on a home visit with a client taking Amiodarone. Which of these statements would indicate that the client understands the potential drug side effects.
- A. It is normal if I have numbing or tingling in my feet.
- B. I need to make sure I wear sunblock when going outdoors.
- C. I need to take supplemental vitamin B12.
- D. I should avoid eating leafy vegetables.
Correct Answer: B
Rationale: Amiodarone can cause increased photosensitivity, so the client should ensure that he or she wears protection.
The severely depressed client tells the nurse, “I don't need these antidepressants; they're too expensive! I'm going to use St. John's wort instead.†Which is the most appropriate response by the nurse?
- A. It would be a safe alternative, especially if you need to watch your finances.
- B. What about taking St. John's wort and an antidepressant for greater effectiveness?
- C. St. John's wort may cost less, but it has not been shown to improve severe depression.
- D. I have some information showing the effective use of St. John's wort. Let's go over it.
Correct Answer: C
Rationale: St. John's wort has not been clinically proven effective for severe depression.
The LPN is teaching a first-time mother about breastfeeding her newborn. Which statement, if made by the mother, would reflect that the teaching had been successful?
- A. My baby should be having at least 4-6 wet diapers a day until 1 month.
- B. It's nice that breastfed babies eat a bit less than formula fed babies.
- C. My baby should be nursing 8-12 times a day during this period.
- D. I'm a little nervous about my milk coming in tomorrow. I've heard it's uncomfortable.
Correct Answer: C
Rationale: Newborns should be nursing 8-12 times during the newborn period. Until a mother's milk comes in, babies typically have a wet diaper count that corresponds to the number of days since their birth (one wet diaper for a 1-day-old baby, and so on). Once they are getting milk and not colostrum, infants should have 4-6 wet diapers a day. A mother's milk usually comes in 3-4 days after the initial colostrum stage. Breast milk is digested faster than formula, so breastfed babies typically eat more frequently.