Nokea
Which medication instructions should the nurse provide to a client who has been prescribed levothyroxine? Select all that apply.
- A. Monitor your own pulse rate.
- B. Take the medication in the morning.
- C. Take the medication at the same time each day.
- D. Notify the primary health care provider if chest pain occurs.
- E. Expect the pulse rate to be greater than 100 beats per minute.
- F. It may take 1 to 3 weeks for a full therapeutic effect to occur.
Correct Answer: A,B,C,D,F
Rationale: Levothyroxine is a thyroid hormone. The client is instructed to monitor her or his own pulse rate. The client is also instructed to take the medication in the morning before breakfast to prevent insomnia and to take the medication at the same time each day to maintain hormone levels. The client is told not to discontinue the medication and that thyroid replacement is lifelong. Additional instructions include contacting the primary health care provider if the rate is greater than 100 beats per minute and notifying the primary health care provider if chest pain occurs, or if weight loss, nervousness and tremors, or insomnia develops. The client is also told that full therapeutic effect may take 1 to 3 weeks and that he or she needs to have follow-up thyroid blood studies to monitor therapy.
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A client has a total serum calcium level of 7.5 mg/dL (1.88 mmol/L). Which clinical manifestations should the nurse expect to note on assessment of the client? Select all that apply.
- A. Constipation
- B. Muscle twitches
- C. Negative Chvostek's sign
- D. Positive Trousseau's sign
- E. Hyperactive deep tendon reflexes
- F. Prolonged ST interval on electrocardiogram (ECG)
Correct Answer: B,D,E,F
Rationale: Hypocalcemia is a total serum calcium level less than 9 mg/dL (2.25 mmol/L). Clinical manifestations include muscle twitches, hyperactive deep tendon reflexes, positive Trousseau's sign, and prolonged ST interval on ECG. Negative Chvostek's sign and constipation are not associated with hypocalcemia.
The nurse, while caring for a hospitalized infant being monitored for increased intracranial pressure (ICP), notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which conclusion should the nurse draw?
- A. That no action is required.
- B. The head of the bed needs to be lowered.
- C. The infant needs to be placed on NPO status.
- D. The primary health care provider should be notified immediately.
Correct Answer: A
Rationale: A bulging anterior fontanel in an infant when crying is a normal finding, as crying increases intracranial pressure temporarily. This does not indicate a pathological condition requiring immediate intervention. Lowering the head of the bed or placing the infant on NPO status is not warranted, and notifying the primary health care provider is unnecessary unless other signs of increased ICP, such as persistent bulging at rest, irritability, or lethargy, are present.
A client who underwent peripheral arterial bypass surgery 16 hours ago reports that there is increasing pain in the leg that worsens with movement and is accompanied by paresthesias. Based on these data, which action should the nurse take?
- A. Call the primary health care provider.
- B. Administer an opioid analgesic.
- C. Apply warm moist heat for comfort.
- D. Apply ice to minimize any developing swelling.
Correct Answer: A
Rationale: Compartment syndrome is characterized by increased pressure within a muscle compartment caused by bleeding or excessive edema. It compresses the nerves in the area and can cause vascular compromise. The classic signs of compartment syndrome are pain at rest that intensifies with movement and the development of paresthesias. Compartment syndrome is an emergency, and the primary health care provider is notified immediately because the client could require an emergency fasciotomy to relieve the pressure and restore perfusion.
The nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse should instruct mothers to take which action?
- A. If antibiotic ointment has been applied to the cord, it is not necessary to do anything else to it.
- B. All that is necessary is to wash the cord with antibacterial soap and allow it to air-dry once a day.
- C. Apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause pain to the newborn infant.
- D. Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day.
Correct Answer: D
Rationale: The cord and base should be cleansed with alcohol (or another substance as prescribed) thoroughly, two to three times per day. The steps are (1) lift the cord; (2) wipe around the cord, starting at the top; (3) clean the base of the cord; and (4) fold the diaper below the umbilical cord to allow the cord to air-dry and prevent contamination from urine. Antibiotic ointment is not normally prescribed. Continuation of cord care is necessary until the cord falls off within 7 to 14 days. Water and soap are not necessary; in fact, the cord should be kept from getting wet. The infant does not feel pain in this area.
The emergency department nurse is assessing a client who abruptly discontinued benzodiazepine therapy and is experiencing withdrawal. Which manifestations of withdrawal should the nurse expect to note? Select all that apply.
- A. Tremors
- B. Sweating
- C. Lethargy
- D. Agitation
- E. Nervousness
- F. Muscle weakness
Correct Answer: A,B,D,E
Rationale: Benzodiazepines should not be abruptly discontinued because withdrawal symptoms are likely to occur. Withdrawal symptoms include tremor, sweating, agitation, nervousness, insomnia, anorexia, and muscular cramps. Withdrawal symptoms from long-term, high-dose benzodiazepine therapy include paranoia, delirium, panic, hypertension, and status epilepticus. Lethargy is not associated with benzodiazepine withdrawal.