Nokea
Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
- A. Fine hand tremor, headache, mental dullness
- B. Vomiting, impaired consciousness, decreased blood pressure
- C. Polyuria, polydipsia, edema
- D. Gastric irritation, nausea, diarrhea
Correct Answer: B
Rationale: These symptoms of lithium toxicity are usually dose related.
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A client with a history of gout is receiving Allopurinol (Zyloprim). The nurse should teach the client to:
- A. Increase fluid intake
- B. Avoid dairy products
- C. Take the medication on an empty stomach
- D. Limit protein intake
Correct Answer: A
Rationale: Allopurinol reduces uric acid, and increased fluid intake promotes uric acid excretion, preventing kidney stones. Dairy, empty stomach, and protein limits are not necessary.
A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?
- A. She is compliant with her diet as previously taught.
- B. She needs further instruction and reinforcement.
- C. She needs to increase her caloric intake.
- D. She needs to be placed on a restrictive diet immediately.
Correct Answer: B
Rationale: She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weight gain, PIH should also be suspected. She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. Restrictive dieting is not recommended during pregnancy.
Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?
- A. 136/88 to 144/93
- B. 132/78 to 124/76
- C. 114/70 to 140/88
- D. 140/90 to 148/98
Correct Answer: C
Rationale: PIH is indicated by a systolic increase of 30 mm Hg or diastolic increase of 15 mm Hg; 114/70 to 140/88 shows a 26 mm Hg systolic and 18 mm Hg diastolic change, most significant for PIH.
A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which medication would the nurse expect to administer?
- A. Ibuprofen (Advil)
- B. Omeprazole (Prilosec)
- C. Aspirin
- D. Acetaminophen (Tylenol)
Correct Answer: B
Rationale: Omeprazole, a proton pump inhibitor, reduces acid production, aiding ulcer healing. Ibuprofen (A) and aspirin (C) worsen ulcers, and acetaminophen (D) addresses pain but not acid.
A female client at 37 weeks' gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:
- A. Reactive; needs follow-up contraction stress test
- B. Reactive; no contraction stress test required
- C. Non-reactive; needs follow-up contraction stress test
- D. Non-reactive; no contraction stress test required
Correct Answer: B
Rationale: A contraction stress test is unnecessary following a reactive (normal) nonstress test. The results are considered reactive, indicating that the fetus is not showing distress. Therefore, a contraction stress test, which is a more in-depth test for fetal distress, is unnecessary. A nonreactive test would show fewer than two fetal movements or a failure of the FHR to increase at least 15 bpm with the movements in a 20-minute period. A contraction stress test should follow a nonreactive nonstress test to validate fetal distress.