Nokea
Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?
- A. Orthostatic hypotension is a common side effect.
- B. Most antipsychotic drugs cause elevated blood pressure.
- C. This provides information on the amount of sodium allowed in the diet.
- D. It will indicate the need to institute anti-parkinsonian drugs.
Correct Answer: A
Rationale: The correct answer is A because monitoring for orthostatic hypotension is crucial when clients are receiving antipsychotic drugs since it is a common side effect. Orthostatic hypotension can lead to symptoms like dizziness and falls, making it essential to monitor blood pressure regularly. Choices B, C, and D are incorrect because most antipsychotic drugs do not typically cause elevated blood pressure, monitoring blood pressure is not directly related to the amount of sodium in the diet, and blood pressure monitoring is not primarily used to determine the need for anti-parkinsonian drugs in clients receiving antipsychotic medications.
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While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?
- A. As you urinate more, you will need less medication to control fluid.
- B. You will have to take this medication for about a year.
- C. The medication must be continued so the fluid problem is controlled.
- D. Please talk to your health care provider about medications and treatments.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect?
- A. Decreased deep-tendon reflexes
- B. Skeletal muscle weakness
- C. Hypoactive bowel sounds
- D. Tingling of the lips
Correct Answer: D
Rationale: The correct answer is D, tingling of the lips (perioral tingling). This is a common symptom of hypocalcemia due to increased neuromuscular excitability. Choice A, decreased deep-tendon reflexes, is more indicative of hypercalcemia. Choice B, skeletal muscle weakness, is associated with hypokalemia. Choice C, hypoactive bowel sounds, is not a typical finding in hypocalcemia.
The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. Exercise by doing weight-bearing activities
- B. Exercise to reduce weight
- C. Avoid exercise activities that increase the risk of fracture
- D. Exercise to strengthen muscles and thereby protect bones
Correct Answer: A
Rationale: The most important instruction for a 65-year-old female client diagnosed with osteoporosis regarding exercise is to engage in weight-bearing activities. Weight-bearing exercises are crucial in maintaining bone density and preventing osteoporosis-related fractures. Choice B is incorrect because the primary focus should be on bone health rather than weight reduction. Choice C is incorrect as avoiding all exercise activities that increase the risk of fracture would limit physical activity, which is essential for overall health. Choice D is incorrect as while strengthening muscles is beneficial, weight-bearing activities directly impact bone health in osteoporosis.
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is:
- A. difference in the intake and output
- B. changes in the mucous membranes
- C. skin turgor
- D. weekly weight
Correct Answer: D
Rationale: In a client with altered renal function, monitoring fluid balance is crucial. Weekly weight is the most accurate indicator of fluid balance during the visits as it reflects cumulative changes in the body's fluid status. Changes in intake and output (Choice A) can provide valuable information, but weekly weight is a more direct measure of overall fluid retention or loss. Changes in mucous membranes (Choice B) and skin turgor (Choice C) can be influenced by factors other than fluid balance, making them less reliable indicators in this context.
To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?
- A. Apply suction for no more than 10 seconds
- B. Maintain a sterile technique
- C. Lubricate 3 to 4 inches of the catheter tip
- D. Withdraw the catheter in a circular motion
Correct Answer: A
Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.