Nokea
What physical manifestations would cue you that your client is experiencing an escalating level of anxiety?
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
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When teaching a client with chronic obstructive pulmonary disease who will start using fluticasone via MDI twice daily, which instruction should the nurse include?
- A. Monitor your heart rate before each dose.
- B. Inspect your mouth for lesions daily.
- C. Do not use this medication to relieve an acute attack.
- D. Do not skip the morning dose even if symptom-free.
Correct Answer: B
Rationale: The correct answer is B: Inspect your mouth for lesions daily. This instruction is essential because fluticasone, a corticosteroid, can cause oral thrush as a side effect. By inspecting the mouth daily, the client can detect any lesions early and seek appropriate treatment. Monitoring heart rate (A) is not necessary for fluticasone use, as it does not typically affect heart rate. While it is important not to skip doses (D), the specific instruction about the morning dose is not as crucial. Avoiding the use of fluticasone for acute attacks (C) is correct, but it is not the most important instruction in this scenario.
A client with asthma is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?
- A. Hypoglycemia
- B. Hypertension
- C. Polyuria
- D. Oral candidiasis
Correct Answer: D
Rationale: The correct answer is D: Oral candidiasis. Fluticasone is a corticosteroid inhaler that can cause oral candidiasis as a common adverse effect due to its immunosuppressive properties. The step-by-step rationale is: 1. Fluticasone is a corticosteroid. 2. Corticosteroids can suppress the immune system. 3. Immunosuppression can lead to oral candidiasis. Other choices are incorrect because: A: Hypoglycemia is not a common adverse effect of fluticasone. B: Hypertension is not typically associated with fluticasone use. C: Polyuria is not a common side effect of fluticasone.
Which of the following would you include as risk factors for the development of skin cancer when assessing the integumentary system?
- A. Advancing age
- B. Positive family history
- C. Dark pigmentation
- D. White collar job
Correct Answer: B
Rationale: Advancing age by itself is not a risk factor. If that person has been exposed to a lot of sun there may be increased risk, but that information is not given here. There is a known genetic risk, with some cancers being seen to be present in families with low risk factors. Those with dark pigmentation develop skin cancer, but at a lower rate than those with low amounts of pigmentation. White collar jobs, which occur in offices and inside buildings, are a low risk for skin cancer.
A 25-year-old client is admitted for a tonsillectomy and informs the nurse of having had episodes of muscle cramps, weakness, and an unexplained temperature elevation. Many years ago, the client's father died shortly after surgery subsequent to developing a high fever. The surgeon has ordered dantrolene sodium (Dantrium) prophylactically prior to the tonsillectomy to reduce the risk of:
- A. a postoperative infection.
- B. malignant hyperthermia.
- C. neuroleptic malignant syndrome.
- D. a postoperative fever.
Correct Answer: B
Rationale: Dantrolene sodium (Dantrium) is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. Dantrolene sodium (Dantrium) is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant hyperthermia is high. Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is not related to malignant hyperthermia. Dantrolene sodium (Dantrium) is a peripheral skeletal muscle relaxant and would have no effect on a postoperative fever.
End-of-life palliative nursing care involves
- A. Constant assessment for changes in physiologic functioning.
- B. Administering large doses of analgesics to keep the patient sedated.
- C. Providing as little physical care as possible to prevent disturbing the patient.
- D. Encouraging the patient and family members to verbalize their feelings of sadness
Correct Answer: D
Rationale: Emotional and psychological support for both the patient and family is crucial in palliative care, helping them process feelings and find closure.