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Which of the following medications should then nurse explain may cause headache as a side effect?
- A. Furosemide (Lasix)
- B. Clonidine (Catapres)
- C. Atenolol ((Tenormin)
- D. Adalat (Procardia)
Correct Answer: B
Rationale: The correct answer is B: Clonidine (Catapres). Clonidine is known to cause headache as a side effect due to its mechanism of action affecting blood pressure regulation in the brain. Furosemide (A) is a diuretic that typically causes electrolyte imbalances, not headaches. Atenolol (C) is a beta-blocker used for hypertension, which can cause fatigue but not typically headaches. Adalat (D) is a calcium channel blocker that usually causes peripheral edema, not headaches.
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The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on potential causes of their fatigue, leading to a more in-depth exploration of the issue. Option A focuses on stress, not necessarily fatigue. Option C is too specific and may not uncover underlying causes. Option D assumes sleep duration is the only factor contributing to fatigue.
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
- A. Exposure to sunlight will help control skin rashes.
- B. There are no activity limitations between flare-ups.
- C. Monitor body temperature
- D. Corticosteroids may be stopped when symptoms are relieved.
Correct Answer: C
Rationale: Rationale:
C: Monitoring body temperature is essential for early detection of infection or fever, which can indicate disease exacerbation in SLE clients.
A: Exposure to sunlight can worsen SLE symptoms due to photosensitivity.
B: Activity limitations are crucial to prevent flare-ups and reduce disease progression in SLE.
D: Corticosteroids should not be stopped abruptly without healthcare provider guidance to prevent symptom recurrence and adrenal insufficiency.
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
- A. Lungs
- B. Liver
- C. Kidneys
- D. Heart
Correct Answer: D
Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications.
Summary:
A: Lungs - Not directly affected by potassium levels.
B: Liver - Not directly affected by potassium levels.
C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
- A. Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Assessment. In this scenario, the nurse failed to assess the patient's condition promptly after being informed of feeling dizzy and light-headed. Assessment involves collecting data to identify actual or potential health problems. By not promptly assessing the patient's worsening condition, the nurse missed an essential step in the nursing process.
Choice B: Diagnosis comes after assessment and involves identifying the patient's health problems based on collected data. Choice C: Implementation is the phase where the nurse carries out the plan of care. Choice D: Evaluation occurs after implementation to determine if the interventions were effective.
A nurse identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for metastatic cancer. What statement or question would be best to validate this client problem?
- A. I have assessed you and find you are fatigued.
- B. I analyzed and interpreted your information as fatigue.
- C. Why are you so tired all the time?
- D. I think fatigue is a problem for you. Do you agree?
Correct Answer: D
Rationale: The correct answer is D because it involves collaboration with the client to validate the identified health problem. By asking the client directly if they agree that fatigue is a problem for them, it promotes client-centered care and empowers the client in their own care. Choice A is incorrect as it assumes the nurse's assessment is enough to confirm fatigue. Choice B is incorrect as it focuses on the nurse's analysis rather than the client's experience. Choice C is incorrect because it is a closed-ended question that may not encourage open communication or validation from the client.