Nokea
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
- A. Steadily increasing vital signs.
- B. Mild tremors and irritability.
- C. Decreased respirations and disorientation.
- D. Stomach distress and inability to sleep.
Correct Answer: A
Rationale: indication that the client is approaching delirium tremens, which can be avoided with additional sedation
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The nurse caring for the child with a large meningomylocele is aware that the priority care for this client is to:
- A. Cover the defect with a moist, sterile saline gauze
- B. Place the infant in a supine position
- C. Feed the infant slowly
- D. Measure the intake and output
Correct Answer: A
Rationale: Moist, sterile gauze prevents infection and drying of the meningomyelocele defect.
A client in cardiac arrest shows to be in torsades de pointes, and magnesium sulfate is ordered STAT. The priority nursing intervention is
- A. monitor client for bradycardia and respiratory depression.
- B. prepare client for synchronized cardioversion.
- C. monitor client for tachycardia and hyperventilation.
- D. prepare client for Swan catheter.
Correct Answer: A
Rationale: Magnesium sulfate for torsades de pointes can cause bradycardia and respiratory depression, requiring close monitoring.
The mother of a 2-year-old asks the nurse when she should schedule her son's first dental visit. The nurse's response is based on the knowledge that most children have all their deciduous teeth by:
- A. 15 months
- B. 18 months
- C. 24 months
- D. 30 months
Correct Answer: D
Rationale: Most children have all 20 deciduous teeth by 30 months, guiding the timing of the first dental visit.
A pregnant woman has experienced repeated vaginal monilial infections. When educating the client about the infection, which information should the nurse include? Select all that apply.
- A. Advise client to bathe daily.
- B. Explain the effects of increased estrogen production.
- C. Advise client to wear cotton panties and avoid nylon or pantyhose.
- D. Suggest client use panty liners to protect clothing.
- E. Advise the client to avoid wearing any panties.
Correct Answer: A,B,C
Rationale: Daily bathing (A), understanding estrogen's role in yeast growth (B), and wearing cotton panties (C) help manage monilial infections. Panty liners (D) may trap moisture, and avoiding panties (E) is impractical.
A schizophrenic client has been taking haloperidol (Haldol) for 20 months and has developed moderate extrapyramidal symptoms (EPS). The nurse anticipates the physician will likely prescribe what medication for EPS?
- A. flumazenil (Anexate)
- B. donepezil (Aricept)
- C. naloxone (Narcan)
- D. benztropine (Cogentin)
Correct Answer: D
Rationale: Benztropine, an anticholinergic, treats EPS (e.g., dystonia, parkinsonism) caused by antipsychotics like haloperidol.