Nokea
When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?
- A. Current dangerous behavior
- B. History of falls
- C. Recent violent attack on a staff member
- D. Refusal to cooperate with treatment
Correct Answer: A
Rationale: Restraints are justified for current dangerous behavior (A) posing immediate risk to self or others. History of falls (B), past violence (C), or non-cooperation (D) do not warrant restraints.
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The nurse is preparing to teach a client about phenytoin sodium (Dilantin). Which fact would be most important to teach the client regarding why the drug should not be stopped suddenly?
- A. Physical dependence can develop over time.
- B. Status epilepticus can develop.
- C. A hypoglycemic reaction can develop.
- D. Heart block can develop.
Correct Answer: B
Rationale: Abruptly stopping phenytoin can precipitate status epilepticus, a life-threatening condition, due to loss of seizure control.
Someone sees a nursing assistant yell at an elderly client and throw his lunch tray off the table. The nursing assistant could likely be charged with
- A. negligence.
- B. assault.
- C. malpractice.
- D. battery.
Correct Answer: B
Rationale: Yelling and throwing a tray constitute assault (threatening behavior causing fear of harm). Battery involves physical contact, negligence involves failure to act, and malpractice applies to professional errors.
An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching plan, the nurse should initially assess:
- A. The client's knowledge of the signs of preterm labor
- B. The client's feelings about the pregnancy
- C. Whether the client was using a method of birth control
- D. The client's thought about future children
Correct Answer: B
Rationale: Assessing the client's feelings about the pregnancy is critical at 10 weeks to tailor education and support to her emotional needs.
The nurse must administer 120 mg of amoxicillin oral suspension to a child. However, the only dosage available in the pharmacy is 200 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using a whole number only.
Correct Answer: 3
Rationale: Dose = 120 mg, concentration = 200 mg/5 mL = 40 mg/mL. Volume = 120 m/40 mg/mL = 3 mL.
Nimotop (Nimodipine) is ordered for the client with a ruptured cerebral aneurysm. The nurse recognizes that the desired effect of this drug is to:
- A. Prevent the influx of calcium into cells
- B. Restore the client's blood pressure to a normal reading
- C. Prevent the inflammatory process
- D. Dissolve the clot that has formed
Correct Answer: A
Rationale: Nimodipine is a calcium channel blocker that prevents calcium influx into vascular smooth muscle cells, reducing vasospasm in cerebral arteries, which is critical in managing ruptured cerebral aneurysms.