Nokea
Which assessment finding requires nursing intervention prior to the administration of medication?
- A. Apical pulse heard best at the pulmonic site
- B. Irregular apical pulse rhythm
- C. Presence of a systolic heart murmur
- D. Apical pulse rate of 50 beats/minute
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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In the emergency department, a child is admitted for accidental ingestion of a poison. The practical nurse (PN) should know that inducing vomiting is recommended for which child?
- A. An 8-month-old who ingested four to six ibuprofen tablets
- B. A 3-year-old who drank an unknown amount of charcoal lighter fluid
- C. A 16-month-old who ingested 2 ounces of acetaminophen elixir
- D. A 2-year-old who ate a handful of automatic dishwasher detergent
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a diagnosis of bipolar disorder is prescribed quetiapine. The nurse should monitor for which potential adverse effect?
- A. Weight gain
- B. Hair loss
- C. Insomnia
- D. Tremors
Correct Answer: A
Rationale: When a client with bipolar disorder is prescribed quetiapine, the nurse should monitor for weight gain as a potential adverse effect. Quetiapine is known to commonly cause weight gain, which can have implications for the client's overall health. Regular monitoring of weight can help in early detection and management of this side effect.
Escitalopram is prescribed for a 16-year-old adolescent client who is clinically depressed. Five days later, the parent tells the practical nurse (PN) that the drug is not working because their child is not feeling any better. Which explanation should the PN provide?
- A. It takes 1 to 4 weeks for antidepressant medications to become effective.
- B. The dosage may need to be increased; I will contact your health care provider.
- C. Depression is difficult to treat with drugs alone. Therapy sessions would enhance their effectiveness.
- D. Based on your child's response to this drug, the health care provider is reviewing your medication regimen.
Correct Answer: A
Rationale: Antidepressant medications typically require 1 to 4 weeks to reach their full therapeutic effect. It is crucial to educate the family that during the initial week of treatment, the child may experience heightened anxiety. Therefore, it is important to wait for the medication to take its full course before assessing its effectiveness.
A client with a diagnosis of schizophrenia is prescribed quetiapine. The nurse should monitor the client for which potential side effect?
- A. Weight gain
- B. Dry mouth
- C. Nausea
- D. Headache
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client who is obtunded arrives in the emergency center with a suspected drug overdose. Intravenous naloxone is given, but within a short period, the client's level of consciousness deteriorates. What action should the nurse take first?
- A. Initiate a second intravenous access site
- B. Prepare to initiate cardiopulmonary resuscitation
- C. Determine the results of the drug toxicity screen
- D. Administer an additional dose of naloxone
Correct Answer: D
Rationale: Administering an additional dose of naloxone should be the first action taken by the nurse in this scenario. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. If the client's level of consciousness deteriorates after the initial dose, administering another dose can help further reverse the overdose effects and improve the client's condition. Once the additional naloxone dose is given, the nurse can then proceed to assess the client's response and consider other interventions as needed.