Nokea
Which of the following would be most important for the nurse to include in the teaching plan for a client who is taking phenelzine (Nardil)?
- A. Eating a normal amount of salt in the diet.
- B. Drinking 10 to 12 glasses of water each day.
- C. Allowing 10 days to achieve therapeutic effects.
- D. Avoiding foods high in tyramine.
Correct Answer: D
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods to prevent hypertensive crisis.
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An elderly client has been bedridden since a cerebrovascular accident that resulted in total right-sided paralysis. The client has become increasingly confused, is occasionally incontinent of urine, and is refusing to eat. In planning the client's care, which of the following factors should the nurse consider as most critical in contributing to skin breakdown in this client?
- A. Nutritional status.
- B. Urinary incontinence.
- C. Episodes of confusion.
- D. Right-sided paralysis.
Correct Answer: A
Rationale: Poor nutritional status impairs skin integrity and healing, making it the most critical factor for skin breakdown.
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when the nurse is
- A. I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: A
Rationale: Suspecting a bladder infection requires immediate medical evaluation, not just a visit to the obstetrician, as infections can trigger preterm labor. The other statements reflect correct understanding of preterm labor management.
A client takes isosorbide dinitrate (Isordil) as an antianginal medication. Which of the following statements indicates that the client understands the adverse effects of the drug?
- A. I should take my pulse before taking the medication.'
- B. I should take Isordil with food.'
- C. I will need to change positions slowly so I won't get dizzy.'
- D. It is important that I report any swelling in my ankles.'
Correct Answer: C
Rationale: Isosorbide dinitrate can cause orthostatic hypotension, so changing positions slowly prevents dizziness, indicating client understanding of adverse effects.
A client with a history of peptic ulcer disease is admitted with hematemesis. The nurse should prioritize which of the following interventions?
- A. Administer pantoprazole intravenously.
- B. Insert a nasogastric tube.
- C. Administer vitamin K.
- D. Position the client supine.
Correct Answer: A
Rationale: Intravenous pantoprazole reduces acid production and stabilizes bleeding in peptic ulcer disease.
The charge nurse determines that the new nurse understands the concepts associated with suicide and suicide intentions when the new nurse makes which statement?
- A. Only the psychotic individual commits suicide.
- B. Suicidal attempts are attention-seeking behaviors.
- C. Suicide runs in the family, so there is nothing that health care personnel can do about it.
- D. Many individuals who commit suicide have talked about their suicidal intentions to others.
Correct Answer: D
Rationale: Most people who do commit suicide have given definite clues or warnings about their intentions. The individual who is suicidal is not necessarily psychotic. A suicide attempt is not an attention-seeking behavior, and each act should be taken very seriously. Suicide is not an inherited condition. The remaining options are considered myths regarding suicide.