Nokea
What is the primary goal collaboratively established by the client with Parkinson's disease, nurse, and physical therapist?
- A. To maintain joint flexibility.
- B. To build muscle strength.
- C. To improve muscle endurance.
- D. To reduce ataxia.
Correct Answer: A
Rationale: Maintaining joint flexibility is the primary goal to prevent contractures and maintain mobility in Parkinson's disease. Strength, endurance, and ataxia (less common in Parkinson's) are secondary.
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A client is given amiodarone (Cordarone) in the emergency department for a dysrhythmia. Which of the following indicates the drug is having the desired effect?
- A. The ventricular rate is increasing.
- B. The absent pulse is now palpable.
- C. The number of premature ventricular contractions is decreasing.
- D. The fine ventricular fibrillation changes to coarse ventricular fibrillation.
Correct Answer: C
Rationale: Amiodarone treats ventricular arrhythmias. A decrease in PVCs indicates the drug is stabilizing the cardiac rhythm, its desired effect.
Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following?
- A. Hypokalemia.
- B. Hyperkalemia.
- C. Hypocalcemia.
- D. Disulfiram (Antabuse)-like symptoms.
Correct Answer: D
Rationale: Sulfonylureas combined with alcohol can cause disulfiram-like symptoms, such as flushing, nausea, and palpitations.
What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.
Which is a priority assessment for the client in shock who is receiving an I.V. infusion of packed red blood cells and normal saline solution?
- A. Fluid balance.
- B. Anaphylactic reaction.
- C. Pain.
- D. Altered level of consciousness.
Correct Answer: B
Rationale: During a blood transfusion in a client in shock, the priority assessment is for an anaphylactic reaction, as transfusion reactions can be life-threatening and require immediate intervention. Fluid balance, pain, and consciousness are monitored but are secondary.