Nokea
Which of the following roommates would be most suitable for the client with myasthenia gravis?
- A. A client with hypothyroidism
- B. A client with Crohn's disease
- C. A client with pylonephritis
- D. A client with bronchitis
Correct Answer: A
Rationale: Hypothyroidism poses no infection risk, unlike pyelonephritis or bronchitis.
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Which instruction would not be included in the discharge teaching of the client receiving chlorpromazine (Thorazine)?
- A. You will need to wear protective clothing or a sunscreen when you are outside.'
- B. You will need to avoid eating aged cheese.'
- C. You should carry hard candy with you to decrease dryness of the mouth.'
- D. You should report a sore throat immediately.'
Correct Answer: B
Rationale: Avoiding aged cheese is relevant for MAO inhibitors, not chlorpromazine, which does not interact with tyramine-containing foods.
The nurse is caring for a postpartum client 2 hours post-delivery who is unable to void. Which of the following nursing interventions should be considered initially?
- A. Insert a straight catheter for residual
- B. Encourage oral intake of fluids
- C. Check perineum for swelling or hematoma
- D. Palpate bladder for distention and position
Correct Answer: D
Rationale: Palpating the bladder assesses for distention, which may indicate urinary retention, guiding further interventions without immediately resorting to invasive measures.
The nurse is performing an admission for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet drug, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect requiring attention.
A client with bipolar disorder is discharged with a prescription for Depakote (divalproex sodium). The nurse should remind the client of the need for:
- A. Frequent dental visits
- B. Frequent lab work
- C. Additional fluids
- D. Additional sodium
Correct Answer: B
Rationale: Depakote requires regular lab monitoring (e.g., liver function, platelet counts) to detect potential side effects like hepatotoxicity or thrombocytopenia.
A client with liver failure and ascites is having a paracentesis to relieve severe dyspnea resulting from abdominal fluid accumulation. Prior to the procedure, the nurse assists the client to urinate. Which of the following is the most important reason to have the patient urinate?
- A. Patient comfort
- B. Prevention of incontinence
- C. Prevention of bladder puncture
- D. Fluid displacement
Correct Answer: C
Rationale: Urinating before paracentesis prevents bladder puncture (C) by emptying the bladder, reducing risk during needle insertion.