Nokea
A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol, characterized by symptoms similar to Parkinson's disease. A shuffling gait, which is a slow, dragging walk with short steps and reduced arm swing, is a classic manifestation. Serpentine limb movement (A) is not associated with pseudoparkinsonism. Nonreactive pupils (C) are not a typical symptom of pseudoparkinsonism. Smacking lips (D) is a sign of tardive dyskinesia, another side effect of antipsychotic medications.
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A nurse is assessing a client who reports taking over-the-counter antacids. Which of the following findings should the nurse identify as a manifestation of hypercalcemia?
- A. Constipation
- B. Decreased urine output
- C. Positive Trousseau's sign
- D. Headache
Correct Answer: A
Rationale: The correct answer is A: Constipation. Hypercalcemia can result from excessive intake of antacids containing calcium carbonate. High levels of calcium in the blood can lead to constipation due to its inhibitory effect on smooth muscle contraction in the intestinal tract. Decreased urine output (choice B) is more indicative of dehydration or renal issues. Positive Trousseau's sign (choice C) is associated with hypocalcemia, not hypercalcemia. Headache (choice D) is a nonspecific symptom and not a typical manifestation of hypercalcemia.
A nurse is caring for a client who is in shock and is receiving an infusion of albumin. Which of the following findings should the nurse expect?
- A. Oxygen saturation 96%
- B. PaCO2 30 mm Hg
- C. Increase in BP
- D. Decrease in protein
Correct Answer: C
Rationale: The correct answer is C: Increase in BP. Albumin is a colloid solution that helps increase blood volume and subsequently improves blood pressure in shock patients. Increasing blood volume leads to an increase in blood pressure. Option A is incorrect because oxygen saturation is not directly affected by albumin infusion. Option B is incorrect because a low PaCO2 level is not a direct effect of albumin infusion. Option D is incorrect because albumin is a protein and its infusion would not lead to a decrease in protein levels.
A nurse is assessing a client who has hypermagnesemia. Which of the following medications should the nurse prepare to administer?
- A. Protamine sulfate
- B. Acetylcysteine
- C. Calcium gluconate
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Calcium gluconate. In hypermagnesemia, there is an excess of magnesium in the blood, leading to muscle weakness, cardiac arrhythmias, and respiratory depression. Calcium gluconate is the antidote for hypermagnesemia as it works by antagonizing the effects of magnesium. By administering calcium gluconate, the nurse can help reverse the symptoms associated with hypermagnesemia and restore normal calcium levels in the body. Protamine sulfate (Choice A) is used to reverse the effects of heparin, acetylcysteine (Choice B) is used as an antidote for acetaminophen overdose, and flumazenil (Choice D) is used to reverse the effects of benzodiazepines. These medications are not indicated for hypermagnesemia.
A nurse is reviewing the list of current medications for a client who is to start a prescription for carbamazepine. The nurse should identify that which of the following medications interacts with carbamazepine?
- A. Nicotine transdermal system
- B. Diphenhydramine
- C. Estrogen-progestin combination
- D. Beclomethasone
Correct Answer: C
Rationale: The correct answer is C: Estrogen-progestin combination. Carbamazepine can decrease the effectiveness of estrogen-containing medications, including estrogen-progestin combinations, by increasing their metabolism. This can lead to reduced contraceptive efficacy and breakthrough bleeding.
Nicotine transdermal system (choice A) does not have a significant interaction with carbamazepine. Diphenhydramine (choice B) is an antihistamine and does not interact with carbamazepine. Beclomethasone (choice D) is a corticosteroid and does not have a significant interaction with carbamazepine.
A nurse is assessing a client following the administration of ondansetron (Zofran). Which of the following findings should indicate to the nurse that the ondansetron has been effective?
- A. Client reports a decrease in pain
- B. Client reports a decrease in nausea
- C. Client reports a decrease in coughing
- D. Client reports a decrease in diarrhea
Correct Answer: B
Rationale: The correct answer is B: Client reports a decrease in nausea. Ondansetron is primarily used to treat nausea and vomiting. If the client reports a decrease in nausea, it indicates that the medication has been effective in managing this specific symptom. Decrease in pain (choice A) is not directly related to the action of ondansetron. Choices C (decrease in coughing) and D (decrease in diarrhea) are not typical indications of ondansetron's effectiveness. It is important for the nurse to focus on the specific expected outcome of the medication, which is the reduction of nausea and vomiting.