Nokea
Which medication requires monitoring for a client with Parkinson's disease?
- A. Antihypertensives.
- B. Levodopa.
- C. Antidepressants.
- D. Antihistamines.
Correct Answer: B
Rationale: Levodopa requires monitoring for efficacy and side effects, as it is a primary treatment for Parkinson's symptoms.
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The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 2 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
For each client finding below, click to specify if the finding is consistent with the disease process of heat exhaustion or heat stroke. Each finding may support more than 1 disease process.
- A. Temperature 105° F (40.5° C)
- B. Confusion
- C. Perspiration
- D. Tachycardia
- E. Signs of dehydration
- F. Hypotension
Correct Answer: A,B,C,D,E,F
Rationale: A (Heat Stroke), B (Heat Stroke), C (Heat Exhaustion), D (Both), E (Both), F (Both). Temperature 104°F and confusion are hallmark signs of heat stroke. Perspiration is typical in heat exhaustion but absent in heat stroke. Tachycardia, dehydration, and hypotension occur in both conditions due to heat stress.
A 52-year-old client with lung cancer tells the nurse that he has a low-grade fever (100.6°F [38.1°C]), nonproductive cough, and increasing fatigue. He completed the radiation therapy to the mass in his right lung and mediastinum 10 weeks ago and has a follow-up appointment to see the physician in 2 weeks. What is the most appropriate response by the nurse?
- A. Advise the client to take two acetaminophen tablets every 4 to 6 hours for 2 days and call back if his temperature increases to 101°F (38.3°C) or greater.
- B. Advise the client that this is an expected side effect of the radiation therapy and to keep his appointment in 2 weeks.
- C. Advise the client to come to the office to be examined today.
- D. Advise the client to go to the nearest emergency department.
Correct Answer: C
Rationale: Fever, cough, and fatigue post-radiation may indicate infection or pneumonitis, requiring prompt evaluation, especially in a lung cancer patient, so an office visit today is appropriate.
A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should?
- A. Assess the dialysis access for a bruit and thrill.
- B. Insert an indwelling urinary catheter and drain all urine from the bladder.
- C. Ask the client to turn toward the left side.
- D. Warm the solution in the warmer.
Correct Answer: D
Rationale: Warming the dialysis solution prevents discomfort and promotes effective dialysis by relaxing abdominal muscles.
The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should:
- A. Apply a half-leg pneumatic compression device
- B. Suggest the client contact her physician
- C. Assess the client for foot ulcers
- D. Encourage the client to avoid standing in one position for long periods of time
Correct Answer: D
Rationale: Distended, tortuous veins suggest varic varicose veins. Avoiding prolonged standing reduces venous pooling and symptom progression. Applying compression devices requires a prescription, contacting a physician is premature, and foot ulcers are not indicated by the description.
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6°F (38.1°C). Which of the following would be a priority outcome for this client?
- A. Prevention of urinary tract complications.
- B. Alleviation of nausea.
- C. Alleviation of pain.
- D. Maintenance of fluid and electrolyte balance.
Correct Answer: C
Rationale: Severe flank pain is the most urgent issue, making pain alleviation the priority outcome to ensure client comfort and stability.