NCLEX-RN from FB (random questions)

The nurse auscultates 40 bowel sounds in 1 minute when assessing the abdomen of a client with pain, nausea, and vomiting. Which statement will the nurse use when documenting this assessment finding? 1. "Absent bowel sounds on auscultation." 2. "Hypoactive bowel sounds heard on auscultation." 3. "Normal bowel sounds heard on auscultation." 4. "Hyperactive bowel sounds heard on auscultation."

4) CORRECT— Hyperactive bowel sounds mean that more than 30 sounds r heard over 1 minute. 1) INCORRECT— Absent bowel sounds mean that no sounds are heard over 3-5 minutes. 2) INCORRECT— Hypoactive bowel sounds mean that one or two sounds are heard over 2 minutes. 3) INCORRECT— Normal bowel sounds mean that 5-30 sounds are heard per minute.

A nurse is caring for a client who was admitted for treatment of alcohol abuse disorder after a motor vehicle collision that occurred while the client was intoxicated. The client tells the nurse, "I drank a lot on the day of the crash because my boss was drinking, and that's expected if we want to advance at my company." Which of the following defense mechanisms is this client displaying? A)Displacement B)Rationalization C)Splitting D)Compensation

ANSWER: B. EXPLANATIONS: B. Rationalization refers to the creation of an acceptable explanation for unacceptable behavior. The client is making an excuse to justify or explain driving while intoxicated. The client thinks the excuse is logical, making his behavior tolerable to him. Incorrect Answers: A. Displacement refers to the transfer of strong or uncomfortable feeling from one person or situation to another, less-threatening situation, person, or object. C. Splitting refers to an inability to accept or resolve both negative and positive attributes in one individual, whether the self or another person. D. Compensation is a defense mechanism characterized by emphasizing strengths to compensate for weaknesses. It can be adaptive if it leads an individual to a healthy and achievable goal or activity. It can also be maladaptive.

A nurse is caring for a hospitalized client who seems on edge when her mother-in-law visits. After one visit, the nurse finds the client upset and in tears. The nurse later asks the client how she felt about the visit, and the client, smiling widely, states, "Oh, my mother-in-law is so reassuring. She can always calm me down." What type of defense mechanism is the client most likely demonstrating? A)Regression B)Reaction formation C)Displacement D)Altruism

ANSWER: B. EXPLANATIONS: B. Reaction formation is a defense mechanism used to manage the individual's response to anxiety and stress by demonstrating a behavior opposite to the the client's feelings. This defense mechanism may be preventing the client from confronting reality or improving the relationship. When a defense mechanism interferes with healthy behaviors, it becomes maladaptive. Incorrect Answers: A. Regression refers to a return to an earlier, childlike behavior in response to stress or conflict. C. Displacement occurs when an individual transfers strong feelings about a person, situation, or object to a less-threatening person, object, or situation. D. Altruism is an adaptive defense mechanism. It is characterized by channeling strong or unpleasant feelings into good works for others.

A nurse is caring for a client with major depressive disorder who has a new prescription for a monoamine oxidase inhibitor (MAOI) antidepressant. Which of the following foods should the nurse advise the client to avoid (select all that apply)? A)White wine B)Cured meats C)Tomato products D)Aged cheeses E)Citrus fruits

ANSWERS: B and D. EXPLANATIONS: B and D. MAOIs are used for the treatment of depression and include phenelzine (Nardil), isocarboxazid (Marplan), and tranylcypromine (Parnate). They inhibit the breakdown of neurotransmitters in the central nervous system, including norepinephrine, dopamine, serotonin, and tyramine. Foods that are rich in tyramine should be avoided since increased tyramine levels can result in a hypertensive crisis that may lead to stroke. This may also result in hyperpyrexia, seizures, coma, or death. These foods include most cheeses, but particularly aged cheeses; cured or smoked meats and fish; figs; overripe bananas in large amounts; avocados; fermented bean curd and fermented soybean or soybean paste; yeast extract; beer and red wine; protein dietary supplements, shrimp paste, soups with protein extract; and soy sauce. Asian restaurants should be avoided, as foods often contain brewer's yeast or sherry, which can trigger a hypertensive crisis. Incorrect Answers: A. Red wines should be avoided. C. Tomatoes are acidic but do not contain significant levels of tyramine. E. FALSE: Citrus fruits do not contain significant levels of tyramine.

About completing Contraception and birth control questions! When instructing a client about the proper use of condoms for pregnancy prevention, which of the following instructions wouldbe included to ensure maximum effectiveness? 1. Place the condom over the erect penis before coitus. 2. Withdraw the condom after coitus when the penis is flaccid. 3. Ensure that the condom is pulled tightly over the penis before coitus. 4. Obtain a prescription for a condom with nonoxynol 9.

Answer: 1. To ensure maximum effectiveness, the condom should always be placed over the erect penis before coitus. Some couples find condom use objectionable because foreplay may have to be interrupted to apply the condom. The penis, covered by the condom, should be withdrawn before the penis becomes flaccid. Otherwise sperm may escape from the condom, providing an opportunity for possible fertilization. Rather than having the condom pulled tightly over the penis before coitus, space should be left at the tip of the penis to allow the condom to hold the sperm. The client does not need a prescription for a condom with nonoxynol 9 because these are sold over the counter.

The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the tx of depression. Which statement by the student indicates a need for further teaching? 1. "A bite block will be placed in the client's mouth to prevent injuries to the tongue n teeth." 2. "Because this client has a mental illness, the agent with medical power of attorney should sign the informed consent document." 3. "The client should have had nothing to eat or drink for at least 6-8 hrs prior to the procedure." 4. "The client will receive a muscle relaxant n short acting anesthetic before the current is delivered."

Answer: 2

The nurse cares for a 46-year-old woman after a traditional cholecystectomy. The patient has a nasogastric tube connected to suction, an IV of D5W infusing into her right arm, and a T-tube and Penrose drain in place. The nurse would be MOST concerned by which of the following findings? 1) The systolic blood pressure is 10 mmHg, lower than it was preoperatively. 2) There is 250 cc of bloody drainage from the T-tube during the first 24 hours. 3) There is 30 cc of serosanguineous drainage in the Penrose drain during the first 24 hours. 4) The patient experiences a 4° temperature elevation the evening after surgery.

Answer: 2. The nurse should expect drainage of 400 ml/day with a gradual decrease. nurse should initially expect bloody drainage then gradually change to greenish-brown. Post-operative fever is very common and is known to occur after all types of surgical procedures, irrespective of the type of anesthesia but need to be monitored. Hypotension may be encountered in any phase of general anesthesia and is common after surgery.

family planning A multigravid client will be using medroxyprogesterone acetate (Depo-Provera) as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching? 1. "This method of family planning requires monthly injections." 2. "I should have my first injection during my menstrual cycle." 3. "One possible adverse effect is absence of a menstrual period." 4. "This drug will be given by subcutaneous injections."

Answer: 3. With medroxyprogesterone acetate, irregular menstrual cycles n amenorrhea r common adverse effects. Other adverse effects include weight gain, breakthrough bleeding, headaches, n depression. This method requires deep intramuscular injections every 3 months. first injection should occur within 5 days after menses.

Following a positive pregnancy test, a client begins discussing the changes that will occur in the next several months with the nurse. The nurse should include which of the following information about changes the client can anticipate in the first trimester? 1. Differentiating the self from the fetus. 2. Enjoying the role of nurturer. 3. Preparing for the reality of parenthood. 4. Experiencing ambivalence about pregnancy.

Answer: 4 Many women in their first trimester feel ambivalent about being pregnant because of the significant life changes that occur for most women who have a child. Ambivalence can be expressed as a list of positive and negative consequences of having a child, consideration of financial and social implications, and possible career changes. During the second trimester, the infant becomes a separate individual to the mother. The mother will begin to enjoy the role of nurturer postpartum. During the third trimester, the mother begins to prepare for parenthood and all of the tasks that parenthood includes.

Standard orders on the nurse's unit include an intravenous infusion of D5 1/4 NS 100ml with 20 mEq (20mmol/L) potassium chloride to run at 100mL per hour. This IV solution would be appropriate for which client diagnosis? SATA 1.Addisonian crisis 2.Hypertension. 3.Chronic renal failure 4.Cushing's disease b.Hypokalemia

Answer: 4 & 5, clients with cramping,Cushing disease and hypokalemia are safe to receive normal saline with potassium chloride. When aldosterone is not secreted,sodium and water is released and potassium levels elevated in response to the hyponatremia and client with renal failure are retaining fluid and potassium

An antenatal client receives education concerning medications that are safe to use during pregnancy. The nurse evaluates the client's understanding of the instructions and determines that she needs further information when she states which of the following? 1. "If I am constipated, magnesium hydroxide (Milk of Magnesia) is okay but mineral oil is not." 2. "If I have heartburn, it is safe to use chewable calcium carbonate (Tums)." 3. "I can take acetaminophen (Tylenol) if I have a headache." 4. "If I need to have a bowel movement, sennosides (Ex-Lax) are preferred.

Answer: 4, Ex-Lax is considered too abrasive to use during pregnancy. In most instances, a Fleet enema will be given before Ex-Lax. Medications for constipation that are considered safe during pregnancy include compounds that produce bulk, such as Metamucil and Citrucel. Colace, Dulcolax, and Milk of Magnesia can also be used. Mineral oil prevents the absorption of vitamins and minerals within the GI tract. The strategies for heartburn are considered safe and Tylenol may be used as an over-the-counter analgesic.

The nurse is caring for a patient 4 hours after undergoing intracranial surgery. Which of the following actions should the nurse take immediately? 1) Turn, cough, n deep-breathe the patient. 2) Place the patient with the neck flexed and head turned to the side. 3) Perform passive range of motion exercises. 4) Move the client to the head of the bed using a turning sheet.

Answer: 4, Move the client to the head of the bed using a turning sheet. The pt's body should be moved as a unit to prevent increased ICP. Great job!

The nurse assesses a woman at 24 weeks' gestation and is unable to find the fetal heart beat. The fetal heart beat was heard at the client's last visit 4 weeks ago. According to priority, the nurse should do the following tasks in which order? All options must be used. 1. Call the health care provider. 2. Explain that the fetal heart beat could not be found at this time. 3. Obtain different equipment and recheck. 4. Ask the client if the baby is or has been moving.

Answer: 4,3,2,1. While initially continuing to attempt to find the fetal heart beat, the nurse can ask the client if the baby has been moving. This will give a quick idea of status. The next step would be to obtain different equipment and attempt to find the fetal heart beat again. A simple statement of fact that the nurse cannot find the heartbeat and is taking steps to rule out equipment error is appropriate. Calling the health care provider would be the last step after it is determined that the baby does not have a heartbeat.

A patient is diagnosed with agoraphobia. Which of the following would the healthcare identify as a characteristic of this disorder? 1. Avoids being in the presence of clowns 2. Avoids interacting with strangers 3. Refuses to use a public restroom 4. Fears the use of public transportation

Answer: 4. Fears the use of public transportation. Agoraphobia is an anxiety disorder in which you fear and avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed

A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal birth. Which of the following responses would be most helpful? 1. "Today's modern technology has resulted in a low maternal mortality rate." 2. "Don't concern yourself with things that happened in the past." 3. "In North America, mothers seldom die in childbirth." 4. "What is it that concerns you about pregnancy, labor, and childbirth?

Answer: 4. The client is verbalizing concerns about death during childbirth, thus providing the nurse with an opportunity to gather additional data. Asking the client about these concerns would be most helpful to determine the client's knowledge base and to provide the nurse with the opportunity to answer any questions and clarify any misconceptions. Although the maternal mortality rate is low in the United States and Canada, maternal deaths do occur, even with modern technology. Leading causes of maternal mortality in the United States and Canada include embolism, pregnancy-induced hypertension, hemorrhage, ectopic pregnancy, and infection. Telling the client not to concern herself about what has happened in the past is not useful. It only serves to discount the client's concerns and block further therapeutic communication. Also, postponing or ignoring client's need for a discussion about complications of pregnancy may further increase the client's anxiety.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply. 1) Do not leave a tourniquet on more than 1 minute while looking for a vein 2) Draw the specimen while the skin is still wet with alcohol prep 3) If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes 4) Use a highly visible vein on the ventral side of the client's wrist 5) Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution

Correct Answers: 1 & 3; A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results. Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a hematoma. (Option 2) Skin preparation involves cleaning using an antiseptic solution and friction and allowing the skin to air dry. Remaining solution may hemolyze and/or dilute the blood sample. Traditionally, alcohol (alone or with povidone iodine) is applied in a circular motion, from insertion site outward (clean to dirty). Current research suggests that the most effective method is applying chlorhexidine (2%) in a back and forth motion, followed by adequate drying time. (Option 4) The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided. (Option 5) The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results. Educational objective: When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

A client with carcinoma of the lungs develops SIADH as a complication of the cancer. The nurse anticipates that the HCP will request which prescriptions? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increase oral fluid intake 4. Decreased oral sodium intake 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

Correct answer: 1256 For client with carcinoma it needs treatment of radiation and chemotherapy. SIADH there is water retention thus decreased sodium or dilutional hyponatremia. In option 1 and 2 are correct. In option 3 Decrease fluid due to water retention. In option 4 increase sodium intake due to hyponatremia. In option 5 correct and medication that is antagonistic to ADH is Declomycin

When performing a basic health assessment, which of the following client characteristics are components of the general survey? (Select all that apply. A.Appearance B.Behavior C.Blood pressure D.Pain level E. Weight

Correct answers: A, B Explanation: During the health assessment, the general survey is made up of the elements that comprise the initial first impression. Such components include the client's overall appearance, behavior, affect, and level of cognitive orientation. Information on items such as the client's weight or pain level is gained later during the assessment process.

I am short stature, low set ears, learning disabilities but can function at very high cognitive levels or very low. Sometimes My palms have a Simian Crease...what was I born with

Down syndrome

Rare condition that causes inflammation in blood vessels of infant n children

KAWASAKIS DISEASE

insulin glargine ,Should you shake the bottle before giving to pt's? (Enc q)

No, protein will be destroyed because insulin is protein

What are signs of ruptured aneurysm

Severe pain, nausea, vomiting, tarchycadia, decreased LOC, hypotension

Situation: Clients with personality disorders have difficulties in their social and occupational functions.Clients with a personality disorder will most likely: Quiz link & rationales : goo.gl/UYzide A. Recover with therapeutic intervention B. Respond to antianxiety medication C. Manifest enduring patterns of inflexible behaviors D. Seek treatment willingly from some personally distressing symptoms

....

A female client reports that she discovered a lump in her breast about 4 months ago, and the lump seems to be getting larger. Which action is most important for the nurse to take? (Answer/Rationale will post in 1 hour) 1. Notify the health care provider to schedule a mammogram. 2. Ask the client if she is taking oral contraceptives. 3. Ask the client the date of her last period. 4. Instruct the client to discontinue any hormones.

1) CORRECT— A mammogram is an x-ray of the breast, which screens for breast cancer. It is the first step to determine whether the lump is malignant or benign. This is the priority action. 2) INCORRECT - This assessment will not help determine the cause of the breast lump. 3) INCORRECT - Pregnancy may cause breast enlargement, but it is generalized enlargement, rather than a localized lump. 4) INCORRECT - The lump should be evaluated and diagnosed first.

A client is admitted to the emergency department (ED) with respiratory compromise. Which assessment finding does the nurse document as indicative of a pneumothorax? 1. Rapid respirations. 2. Deep, rapid respirations. 3. Respiratory depression. 4. Periods of hyperpnea alternating with periods of apnea.

1) CORRECT— This describes tachypnea, a symptom of pneumothorax. 2) INCORRECT — This describes hyperpnea. Hyperpnea causes include metabolic acidosis and diabetic ketoacidosis. This is not associated with pneumothorax. 3) INCORRECT — This occurs with an overdose of benzodiazepines or opioids. It is not associated with pneumothorax. 4) INCORRECT — This describes Cheyne-Stokes respirations, which are caused by a cerebral lesion. It is not associated with pneumothorax.

MAOI's Contraindications 1. Never give with a _____ 2. This is medtake___to_______weeks to work 3.Know the dietary restrictions; your patient will not be allowed to eat anything with _______ in it while taking an a MAOL

1. Never give with a SSRI 2. This is med takes 4 to 6 weeks to work 3.Know the dietary restrictions; your patient will not be allowed to eat anything with tyramine in it while taking an a MAOL

The nurse assesses an older adult client who experienced a stroke. Which findings indicate to the nurse that the client has cognitive impairment? (Select all that apply.) 1. Ataxia. 2. Poor judgment. 3. Upper arm flaccidity. 4. Memory deficits. 5. Flat affect.

2) CORRECT - A client who has intact cognitive function should be able to answer questions appropriately and be able to use good judgment to make decisions. The client who has experienced a stroke may not be able to answer questions appropriately. 4) CORRECT - After a stroke, a client may not remember recent and past events. 1) INCORRECT - Ataxia indicates a dysfunction of the cerebellum. 3) INCORRECT - Upper arm flaccidity indicates a change in lower motor neuron function. This occurs after a stroke. 5) INCORRECT - Following a stroke, the client can show very little emotion or a flat affect. The client may also have personality changes or mood swings.These symptoms indicate behavioral changes.

A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. The nurse should instruct the client to do which of the following? 1. Check the cervical mucus to see if it is thick and sparse. 2. Take her temperature at the same time every morning before getting out of bed. 3. Document ovulation when her temperature decreases at least 1°F (0.56°C). 4. Avoid coitus for 10 days after a slight rise in temperature.

2. The basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the temperature falls by 0.5°F (0.28°C). At the time of ovulation, the temperature rises 0.4°F to 0.8°F (0.22°C to 0.44°C) because of increased progesterone secretion in response to the luteinizing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should keep a diary of about 6 months of menstrual cycles to calculate "safe" days. There is no mucus for the first 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy. CN: Health promotion and maintenance; CL: Apply

A 30-year-old multigravid client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. She is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation on her face and abdomen.These assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy? 1. Positive. 2. Probable. 3. Presumptive. 4. Diagnostic.

2. The plan of care should reflect that this woman is experiencing probable signs of pregnancy. She may be pregnant but the signs and symptoms may have another etiology. An enlarging abdomen and a positive pregnancy test may also be caused by tumors, hydatidiform mole, or other disease processes as well as pregnancy. Changes in the pigmentation of the face may also be caused by oral contraceptive use. Positive signs of pregnancy are considered diagnostic and include evident fetal heartbeat, fetal movement felt by a trained examiner, and visualization of the fetus with ultrasound confirmation. Presumptive signs are subjective and can have another etiology. These signs and symptoms include lack of menses, nausea, vomiting, fatigue, urinary frequency, and breast changes. The word "diagnostic" is not used to describe the condition of pregnancy.

The nurse provides care to a client diagnosed with diabetes mellitus. As the nurse prepares to administer the client's prescribed lispro insulin, the client's son states, "Another nurse already gave my mom her insulin." Which nursing action is most appropriate? 1. Return the unused insulin to the client's medication supply drawer. 2. Document insulin administration on behalf of the client's previous nurse. 3. Contact the nurse from the previous shift. 4. Recheck the client's serum glucose level

3) CORRECT— Contacting the client's previous nurse is the safest action, as this action will allow for confirmation that the prescribed insulin dose was already administered. 4) INCORRECT— In the event that the client's previous nurse already administered the prescribed insulin, the medication may not yet have taken effect. Contacting the nurse from the previous shift is the safest action.

The nurse provides care to a client diagnosed with diabetes mellitus. As the nurse prepares to administer the client's prescribed lispro insulin, the client's son states, "Another nurse already gave my mom her insulin." Which nursing action is most appropriate? (Answer/Rationale will post in 1 hour) 1. Return the unused insulin to the client's medication supply drawer. 2. Document insulin administration on behalf of the client's previous nurse. 3. Contact the nurse from the previous shift. 4. Recheck the client's serum glucose level.

3) CORRECT— Contacting the client's previous nurse is the safest action, as this action will allow for confirmation that the prescribed insulin dose was already administered. 4) INCORRECT— In the event that the client's previous nurse already administered the prescribed insulin, the medication may not yet have taken effect. Contacting the nurse from the previous shift is the safest action.

The nurse provides care for a client who has received preoperative medications. The client insists on getting up and going to the bathroom. Which response by the nurse is most appropriate? (Answer/Rationale will post in 1 hour) 1. "You should have gone to the bathroom before receiving the medications." 2. "You can walk to the bathroom if you are not feeling groggy." 3. "I would suggest that you use the bedpan right now." 4. "I will see if your health care provider can prescribe an indwelling urinary catheter."

3) CORRECT— Preoperative medications may interfere with balance and create a safety concern. The client should remain in bed and be encouraged to use the bedpan. 1) INCORRECT - Because pre-operative medications may interfere with balance, the nurse should have asked the client to void before receiving the medication. This response is not appropriate and non-therapeutic. 2) INCORRECT - Preoperative medications may interfere with balance and create a safety concern. The client should not get up at this time. 4) INCORRECT - Seeking a prescription for an indwelling urinary catheter places the client at an increased risk for an infection. The client needs to be encouraged to use the bedpan.

The nurse provides care for a client after electroconvulsive therapy (ECT). Which observation is of concern to the nurse? 1. The client reports a headache. 2. The client reports memory difficulty. 3. The client appears confused. 4. The client reports a backache.

4) CORRECT— A backache is not an expected effect of ECT. Due to convulsions that may occur during ECT, a fracture could occur in a vertebrae. Less severe, but also of concern, is muscle soreness related to effects of succinylcholine, which causes depolarization of muscles. The use of muscle relaxants before ECT usually prevents these adverse effects. Assess the severity, duration, and location of the client's pain and report the findings to the health care provider. 1) INCORRECT - A headache may occur after ECT but is not a critical observation. 2) INCORRECT - Short-term and long-term memory loss is an expected side effect of the treatment. 3) INCORRECT - Confusion is an expected side effect of the treatment. The nurse should stay with and frequently reorient the client.

During a visit to the prenatal clinic, a pregnant client at 32 weeks' gestation has heartburn. The client needs further instruction when she says she must do what? 1. Avoid highly seasoned foods. 2. Avoid lying down right after eating. 3. Eat small, frequent meals. 4. Consume liquids only between meals.

4. Consuming most liquids between meals rather than at the same time as eating is an excellent strategy to deter nausea and vomiting in pregnancy but does not relieve heartburn. During the third trimester, progesterone causes relaxation of the sphincter and the pressure of the fetus against the stomach increases the potential of heartburn. Avoiding highly seasoned foods, remaining in an upright position after eating, and eating small, frequent meals are strategies to prevent heartburn.

The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the health care provider concerning fetal movement? 1. "If the fetus is becoming less active than before." 2. "If it takes longer each day for the fetus to move 10 times." 3. "If the fetus stops moving for 12 hours." 4. "If the fetus moves more often than 3 times an hour."

4. The fetus is considered well if it moves more often than 3 times in 1 hour. Daily fetal movement counting is part of all high-risk assessments and is a noninvasive, inexpensive method of monitoring fetal well-being. The health care provider should be notified if there is a gradual slowing over time of fetal activity, if each day it takes longer for the fetus to move a minimum of 10 times, or if the fetus stops moving for 12 hours or longer.

A nurse who works for a home care agency is checking the acuity of her clients to be seen. Which of the following clients should be seen first? Rat after 1hr 1.A 50-year-old woman who had a right mastectomy 5 days ago 2.A woman with type I diabetes mellitus who has a pressure ulcer on her left ankle 3.A middle-age man with emphysema 4.A 70-year-old woman with chronic constipation who had a colonoscopy 3 days ago

Ans 1 Because of the invasiveness of the surgery and the possibility of major complications, including infections at the wound site and possible lymph involvement, the client who had the mastectomy should be seen first. Nothing in the question indicates the client with emphysema or the client with diabetes is experiencing emerging problems. The client who underwent a colonoscopy 3 days ago has a chronic condition. Nothing in the question leads to a potential problem, such as bleeding or bowel perforation with the client.

A patient with a history of alcoholism is brought to the emergency room in an agitated state. He is vomiting and diaphoretic. Had his last drink five hours ago. The nurse would expect to administer which of the following medications? 1) Chlordiazepoxide hydrochloride (Librium) 2) Disulfiram (Antabuse) 3) Methadone hydrochloride (Dolophine) 4) Naloxone hydrochloride (Narcan)

Answer: 1, Chlordiazepoxide hydrochloride (Librium). Librium is used to treat symptoms of acute alcohol withdrawal, lethargy, hangover, n agranulocytosis. Antabuse, is used as an effective treatment for chronic alcoholism by discouraging the consumption of alcohol.

The nurse is caring for clients in an orthopedic clinic. Then nurse would be MOST concerned if which of the following was observed? 1) A teenager who is 6'4" tall places the crutches about 6" to the side of his feet when ambulating with crutches. 2) A school-aged child who is 4'8" tall flexes her elbows about 20 degrees when ambulating with crutches. 3) A middle-aged adult, 5'10" tall, advances the crutches first when walking down the stairs. 4) An older adult, 5'6" tall, uses a 4-point gait when ambulating with crutches.

Answer: 1. Taller people require a broader base of support.

The physician orders codeine 60 mg and aspirin grains X PO every four hours, as needed for pain. Each codeine tablet contains 15 mg of codeine. Each aspirin tablet contains 325 mg of aspirin. Which of the following should the nurse administer? 1) 2 codeine tablets and 4 aspirin tablets 2) 4 codeine tablets and 2 aspirin tablets 3) 3 codeine tablets and 3 aspirin tablets 4) 4 codeine tablets and 3 aspirin tablets

Answer: 2, (4 codeine tablets and 2 aspirin tablets). 60/x = 15/1 x = 4 10 grains = 600 mg 325/1 = 600/x x = 2

Which of the following observations of a 8 lb 4 oz newborn boy, if made by the nurse, would require an intervention? 1. The infant's respirations are 36, shallow and irregular in rate, rhythm, and depth. 2. The infant's axillary temperature is 96.2° F (35.6° C). 3. Rapid pulsations are visible in the fifth intercostal space, left midclavicular line. 4. There is asynchronous spontaneous movement of the infant's extremities.

Answer: 2, The infant's axillary temperature is 96.2° F (35.6° C). This subnormal temperature indicates prematurity, infection, low environment temperature, inadequate clothing, and/or dehydration

The nurse provides care for a client 18 hours after a left below-the-knee amputation. Which nursing action is most important? 1. Notify the health care provider (HCP) of increased drainage. 2. Elevate the residual limb on a pillow or other soft surface. 3. Encourage the client to lie in a prone position. 4. Perform active range-of-motion (ROM) exercises on the right leg daily.

Answer: 2, nurse's priority is to reduce risk of complications at the operative site. In the initial post-operative period, limb elevation minimizes edema. Do not elevate the residual limb for more than 24 hours because it will cause hip flexion complications.

The nurse is assessing a client thats has sustained a head trauma from falling out a tree. The nurse notices that the client's left pupil ia fixed and dilated. The nurse is aware that damage has been done to which cranial nerve? 1. CN I 2. CN II 3. CN III 4. CN IV

Answer: 3

While inserting a nasogastric tube, the nurse should use which of the following protective measures? 1. Gloves, gown, goggles, and a surgical cap. 2. Sterile gloves, mask, plastic bags, and gowns. 3. Gloves, gown, mask, and goggles. 4. Double gloves, goggles, mask, and surgical cap.

Answer: 3 Gloves, gown, mask, goggles.

A 7-year-old girl with insulin-dependent diabetes (IDDM) has been home sick for several days and is brought to the emergency department by her parents. A diagnosis of ketoacidosis is made. The nurse would expect to see which of the following lab results for this client? 1) Serum glucose 140 mg/dL 2) Serum creatine 5.2 mg/dL 3) Blood pH 7.28 4) Hematocrit 38%

Answer: 3, ...

The nurse is performing discharge teaching on a patient with chronic renal failure. The nurse knows that teaching has been successful if the patient selects which of the following menus? 1) 6 oz roast beef, baked potato, 1/2 broccoli, one orange, and 16 oz of iced tea. 2) 4 oz baked ham, 1/2 potatoes au gratin, 1/2 cup canned green beans, one apple, and 8 oz of milk. 3) 2 oz turkey, 1/2 noodles, 1/2 carrots, 1/2 cup blueberries, and 8 oz cola. 4) Hot dog with bun, 1/2 cup pork and beans, 1 cup of spinach salad, 1 banana, and 8 oz lemonade.een successful if the patient selects which of the following menus?

Answer: 3, 2 oz turkey, 1/2 noodles, 1/2 carrots, 1/2 cup blueberries, and 8 oz cola. This meal has the appropriate amount of protein, low potassium fruit, and a protein-free drink. A chronic kidney disease diet limits protein, phosphorus, sodium, and potassium. Liquids may also need to be limited in later stages of chronic kidney disease. This diet can help slow down the rate of damage to your kidneys.

nurse is caring for pregnant client in labor who is to undergo General anesthesia. nurse understands that which are adverse effects of this therapy? Select all that apply: 1. Headache 2. Sleepiness 3. Aspiration 4. Respiratory depression 5. Lowered blood pressure

Answer: 3, 4 rationale: adverse effects of general anesthesia for any client include aspiration, respiratory depression. Headache, sleepiness n lowered blood pressure may occur but these r not adverse effects but rather side effects of general anesthesia Test taking strategy: note the subject, adverse effects of general anesthesia. Recalling that headache, sleepiness, lowered blood pressure can occur but not life threatening effects of this therapy will assist u in eliminating these options

family planning A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes thatoccur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client's teaching plan? 1. About midway through the menstrual cycle, cervical mucus is thick and sticky. 2. During ovulation, the cervix remains dry without any mucus production. 3. As ovulation approaches, cervical mucus is abundant and clear. 4. Cervical mucus disappears immediately after ovulation, resuming with menses.

Answer: 3. As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white. Ovulation generally occurs 14 days (±2 days) before the beginning of menses. During the luteal phase of the cycle, which occurs after ovulation, the cervical mucus is thick n sticky, making it difficult for sperm to pass. Changes in the cervical mucus are related to the influences of estrogen and progesterone. Cervical mucus is always presen

Using Nägele's rule for a client whose last normal menstrual period was from10th to 14th of May, the nurse determines that the client's estimated date of childbirth would be which of the following? 1. January 13. 2. January 17. 3. February 13. 4. February 17.

Answer: 4 - Nagele's rule is 9 months plus 7 days from the first day of last menstrual period . 4. When using Nägele's rule to determine the estimated date of childbirth, the nurse would count back 3 calendar months from the first day of the last menstrual period and add 7 days. This means the client's estimated date is February 17.

The nurse is caring for a 67-year-old man four days after a suprapubic prostatectomy. The physician has removed the Foley catheter. A suprapubic (S/P) catheter remains in place. Which of the following actions, if taken by the nurse, is MOST appropriate? 1) Encourage the patient to void; measure the amount of urine voided and drained from the suprapubic catheter; document the results. 2) Clamp the suprapubic catheter for two hours, release the clamp, allow it to drain to gravity; measure and document the results. 3) Encourage the patient to void every two hours with the suprapubic catheter clamped; open the clamp, allow the catheter to drain to gravity, and document the results. 4) Clamp the suprapubic catheter; have the patient void; unclamp the catheter, and allow it to drain to gravity; measure and document the results.

Answer: 4, Clamp the suprapubic catheter; have the patient void; unclamp the catheter, and allow it to drain to gravity; measure and document the results. This checks for residual urine in the bladder after voiding. When residual urine is 75 ml or less the S/P catheter is usually removed.

A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, the nurse determines that an appropriate outcome for the couplewould be to accomplish which of the following by the end of this visit? 1. Choose an appropriate infertility treatment method. 2. Acknowledge that only 50% of infertile couples achieve a pregnancy. 3. Discuss alternative methods of having a family, such as adoption. 4. Describe each of the potential causes and possible treatment modalities.

Answer: 4. By the end of the first visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evaluation shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be difficult, painful, or risky. The first visit is not the appropriate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infertility, a crisis for most couples. Although the couple may be in a hurry for definitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treatment, but insufficient data are available to suggest that a specific treatment modality may not be successful. Suggesting that the couple consider adoption at this timemay inappropriately imply that the couple has no other choice. If a specific therapy may result in a pregnancy, the couple should havetime to consider their options. After a thorough evaluation, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility.

The nurse is teaching a 45-year-old woman how to increase the potassium in her diet. The woman says she knows bananas are high in potassium, but she doesn't like their taste. What foods should the nurse recommend the client include in her diet? A. Potatoes, spinach, raisins. B. Rhubarb, tofu, celery. C. Carrots, broccoli, yogurt. D. Onions, corn, oatmeal.

Answer: A

When caring for a patient during an acute panic attack, which of the following actions by the healthcare provider is most appropriate? A. Offer the patient reassurance of safety and security B. Explore common phobias associated with panic attack C. Ask open-ended questions to encourage communication D. Use distraction techniques to change the patient's focus

Answer: A, Offer the patient reassurance of safety and security.

A nurse cares for a group of clients on a nursing care unit. Which client does the nurse assess first? 1) A client with a circumferential burn to the upper arm reporting tingling in the fingers 2. A client with hepatic encephalopathy reporting tremors in the hands 3. A client with rhabdomyolysis reporting muscle weakness and dark brown urine 4. A client with acute coronary syndrome on a nitroglycerin infusion reporting a dull headache

Answer: A, RATIONALE: circumferential burn increases the likelihood of a client suffering from compartment syndrome, a medical emergency of increased pressure within a compartment of the body. This increased pressure decreases blood supply and causes parathesia (tingling) in the impacted area. Additional symptoms of compartment syndrome may include pain, paralysis, and decreased or absent distal pulses.

The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following? a) Reed-Sternberg cells. b) Duchenne's cells. c) Tay-Sachs cells. d) Sarcoidosis cells.

Answer: A, Reed-Sternberg cells. A definitive diagnosis of Hodgkin's disease is made if Reed-Sternberg cells are found in the histologic examination of the excisional lymph node biopsy. Tay-Sachs disease is an inherited disease carried by an autosomal recessive gene. Sarcoidosis is an inflammatory granulomatous disease. Duchenne's disease is a type of muscular disorder.

Nurse Sizley asked the client if she could assist in cutting toenails. Which of the following should be done initially when toenails are thick and diicult to cut? A. Rough edges will be file first B. Soak the feet in warm water C. Cream is masages into the nails D. Antiseptic is applied to the nails

Answer: B

The tympanic membrane is placed in the canal at an angle of _____ degrees with the floor. a). 30 b). 45 c). 55 d).135 e).150

Answer: B

The nurse in the out-patient clinic evaluates the Mantoux test of a 36-year-old woman. The woman's history indicates that she has been treated during the past year for an AIDS-related infection. The nurse should document that there was a positive reaction if there was an area of induration measuring what? 1) 3 mm 2) 7 mm 3) 11 mm 4) 15 mm

Answer: B, 7 mm. If a measurement greater than a 5 mm area positive for patient with an HIV-infection history.

Anaphylactic reaction after administering penicillin indicates A. An acquired atopic sensitization B. Passive immunity to penicillin allergen C. Antibodies to penicillin developed after earlier use of the drug D. Developed potent bivalent antibodies when the IV administration was started

Answer: C

5. The nurse knows that teaching about plant alkaloids has been successful when the client states the following: 1. I will stay out of the sun 2. I won't eat aged cheese 3. I will increase the fiber in my diet 4. I know my urine wil turn red

Correct ansnwer: 3 Vinca/Plant Alkaloids is a cell cycle specific type of chemotherapy. Ex: Vincristine, Vinblastine. Side effect is constipation. Encourage to increase oral fluid intake n fiber.

A nurse is caring for an adult client who has been treated with antidepressants for a year and recently received a new prescription for antianxiety medication. The client says to the nurse, "I have reached the bottom of the barrel now. I have to take both Prozac [fluoxetine] and Klonopin [clonazepam] to control my symptoms." Which of the following is the best response by the nurse? A)"If the medications work, why worry? Just take them, and be happy they are effective." B)"I can understand your concern. Those psychiatric medications are pretty potent." C)"It seems you are concerned your illness may be worsening. Tell me more about that." D)"You seem to feel guilty about taking psychiatric medications for your illness. There is nothing to feel guilty about."

Correct answer: (C) "It seems you are concerned your illness may be worsening. Tell me more about that." The nurse should confirm the client's concern about taking the medications. Expressing concern is likely to promote further discussion. Incorrect Answers: A. This response does not recognize the client's struggles; the nurse should instead give the client an opportunity to talk. B. The nurse cannot necessarily understand how the client feels; she must talk to the client more to get a better idea of why the client is upset. D. This is a dismissive response and should be avoided.

A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being more effectively treated by second-generation antipsychotics rather than first-generation antipsychotics? (Select all that apply.) A)Auditory hallucinations B)Withdrawal from social situations C)Inability to make decisions D)Severe agitation E)Anhedonia

Correct: B)Negative symptoms of schizophrenia indicate a loss or decrease in the ability to function in areas such as affect, volition, interpersonal relationships, and psychomotor activity. Manifestations, such as social withdrawal, impaired social interaction, and lack of personal insight, are negative symptoms associated with interpersonal relationships. Negative symptoms are more effectively treated with second-generation antipsychotics. C) An inability to make decisions is an example of negative symptoms which involve both apathy and emotional ambivalence. Negative symptoms of schizophrenia are more effectively treated with second-generation antipsychotics. E) Negative symptoms of schizophrenia indicate the client is experiencing a loss or decrease in the ability to function. This loss impacts areas such as affective, volition, interpersonal relationships, psychomotor behaviors, as well as associated behaviors, resulting in inability to obtain enjoyment from life, or anhedonia, and regression, or the retreat to an earlier state of development. Negative symptoms are more effectively treated with second-generation antipsychotics.

A nurse is assessing a client who received an increased dose of fluvoxamine 4 hr ago. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (Select all that apply.) A.Hypothermia B.Hallucination C.Muscular flaccidity E.Tachycardia F.Agitation

Correct: B)Serotonin syndrome is thought to be caused by a medication dosage that is too high or as interaction with other medications that results in overactivation of central serotonin receptors. The increased uptake of serotonin by the receptors can cause mental status changes, such as delirium, irrational thinking, and hallucinations. D) Cardiovascular manifestations of serotonin syndrome include tachycardia, labile blood pressure, and cardiovascular shock. Respiratory manifestations, such as apnea, can also occur. E) The risk for the development of serotonin syndrome is increased if the client is taking a second agent that increases serotonin, such as a monoamine oxidase inhibitor. The increased levels of serotonin can result in neurologic manifestations, such as agitation, hostility, and mood swings. Incorrect Answers: A. Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI), which is used in the treatment of obsessive compulsive disorder. A potentially life-threatening adverse effect of SSRIs is the development of serotonin syndrome. This syndrome causes a number of manifestations that affect the autonomic stability, which results in tachycardia, labile blood pressure, and fever. C. Musculoskeletal effects are also seen with serotonin syndrome. Manifestations such as hyperreflexia, myoclonus, and incoordination are seen. These manifestations should be an indication to the nurse that the client might have developed serotonin syndrome.

Lithium Is a electrolyte thats also a mood stabilizer Therapeutic level is __________!- lithium can become ______ in the system quick Give with ___ Do not give with ____ What 2 things can cause toxicity? This is not a _____ is acting drug med will work after _____ weeks, Also must be ____ off do not _______

Is a electrolyte thats also a mood stabilizer Therapeutic level is 0.6-1.2!-lithium can become toxic in the system quick Give with food Do not give with diuretics Low sodium/hyponatremia can cause toxicity This is med will work after 2weeks,not a fast is acting drug Also must be tapered off do not stop abruptly

3 SSRI SIDE EFFECTS ?

Sexual dysfunction headache ABCD's

Tyramine restricted diet for MAOI Meats-no organ or preserved Grains-no grains with active yeast Vegetables- No BAR (Banana, Avocado or Raisins) Fruits- No BAR again Dairy-no cheese except cottage cheese, no yogurt Sweets/oils-no coffees, teas or chocolate Condiments-no soy sauce

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Wt r the steps to use the metered dose inhaler?

...

What are the 4 MAOI meds ?

1. Marplan(Isocarboxazid)= eye-so-kar-BOX-a-zid 2. Nardil (Phenelzine) FEN-L-zeen 3. Pardate (Tranylcypromine) tran-no-Sye-foe-meen 4.) selegiline ( Eldepryl)

48. A nurse manager is open minded, listens to the team, understands others, makes changes to improve unit operations and procedures. What type of leadership style is this? A. Situational B. Democratic C. Compassionate D. Transformational

Answer: B

Wt is the best diet for ARF?

High carb, low protein

Digoxin toxicity symptoms

Yellow spots, nausea, vomiting, abdominal pain

How should the nurse assess in crepitus in client with subconscious emphysema

auscultation

The mineral which is considered important in maintaining electrical potential in nerves and membranes is A. magnesium.. B. manganese C. calcium D. iron

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A client who is to undergo hyperbaric oxygen therapy asks the nurse "is it painful?" The appropriate response of the nurse is:

"No, although u may feel some fullness in ur ears." (HBOT is painless procedure, however, it has potential side effects including ear trauma, Central nervous system disorder n oxygen toxicity

Most Atypical antipsychotics end in__? Except Risperidone & Quetiapine ( seroquel)

"Pine"

List some discharge instructions for BPH:

...

MAOI What type med is it? What does this med do? Which make you ?

Antidepressants These meds help u hold onto longer 1. norepinephrine 2. Dopamine 3. Serotonin Which will make u happier

What type of is selegiline ( Eldepryl)?

Maoi

What is Citalopram sye-TAL-oh-pram What's the brand name ? Do not take ______ or _______ with this med

(Celexa) Do not take alcohol or drive with this med SSRI

venlafaxine ven-la-FAX-zeen What's the brand name ? Do not give with ______ or _______ will cause _____ , give _____

(Effexor ) Do not give with lithium or Cimetidine will cause insomnia , give early SSRI

What is Fluoxetine floo-OX-e-teen What's the brand name ? Causes _____ in children/adults Will cause ____ When do you give this med ?

(Prozac) A SSRI Causes suicidal ideation in children Will cause insomnia Give early before 2pm

The ABCDs of psych med side effects ! A-altered vital signs ( Brady , low BP ) B- blurred vision C- constipation, confusion D-dry mouth , dizziness S-statsis of urine (also known as urinary retention , sedation Can be use as a anti-convulsants Sedatives and relaxes muscles Sedatives and relaxes muscles

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The nurse in a community clinic evaluates a client diagnosed with type 1 diabetes mellitus. Which observation indicates to the nurse that the client is not rotating insulin injection sites? 1. Wheal present at an injection site. 2. Discomfort at an injection site. 3. Glucose levels rise temporarily. 4. Increased muscle mass at injection site.

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What are the nursing interventions for acute renal failure

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Standard orders on the nurse's unit include an intravenous infusion of D5 1/4 NS 100ml with 20 mEq (20mmol/L) potassium chloride to run at 100mL per hour. This IV solution would be appropriate for which client diagnosis? SATA 1.Addisonian crisis 2.Hypertension. 3.Chronic renal failure 4.Cushing's disease b.Hypokalemia

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Defense mechanisms Sublimation = technique where maladaptive thoughts and feelings are channeled into socially acceptable behaviors Projection = blaming or attributing faults to another person. Displacement = transferring responses from one person to another person or object. Splitting of self-image = inability to integrate positive and negative aspects of one's self. Denial = commonly used defense mechanism among individuals with substance use disorders. Rationalization = use of "acceptable" explanation to excuse unacceptable behavior (e.g. if the client admitted to taking 40 pills a day but states the medications were prescribed by a doctor for back pain, while failing to acknowledge that the medications were obtained through visits to multiple doctors in order to obtain large quantities.) Reaction formation = defense mechanism used to manage the individual's response to anxiety and stress by demonstrating a behavior opposite to the the client's feelings. This defense mechanism may be preventing the client from confronting reality or improving the relationship. When a defense mechanism interferes with healthy behaviors, it becomes maladaptive. Regression = return to an earlier, childlike behavior in response to stress or conflict. Altruism = adaptive defense mechanism. It is characterized by channeling strong or unpleasant feelings into good works for others. Dissociation = ability to compartmentalize. A client who is exhibiting dissociation might describe being part of a fantasy world or behave as if disconnected from reality. Dissociation can be a positive defense mechanism, such as when an individual reading or studying outside is able to block out visual and noise distractions to stay engaged in the desired behavior. Introjection = incorporating outside factors into oneself. For example, an adolescent might adopt the thoughts and attitudes of peers into their own conscience or values. Repression = unconscious ability of the mind to forget a stressor. This can occur following traumatic events and is suspected when an individual is unable to recall details regarding the event.

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Phenothiazine Drugs that end in ? What type of drug is this ? This help patients associated with ? Name those problems What route can it be given

All end in azine except Haloperidol (haldol) &. Thiothixene (Navene) This is med is typical antipsychotic and will help patients with problems associated with schizophrenia (delusions, hallucinations, and paranoia) -positive symptoms Route given : PO, IV or IM ( IM last the longest

A nurse is caring for a client with Parkinson's disease who began treatment 2 days earlier with selegiline (Eldepryl), a monoamine oxidase inhibitor. Which of the following should the nurse look for when assessing the client? A)Muscular rigidity and drooling B)Seizures C)Tachycardia and headaches D)Excessive thirst and dry mouth

ANSWER: C. EXPLANATIONS: C. TRUE: Selegiline (Eldepryl) is a monoamine oxidase inhibitor (MAOI.) Monoamine oxidase inhibitors are associated with a risk of hypertensive crisis, which is characterized by tachycardia, palpitations, headaches, and vomiting. A hypertensive crisis requires immediate notification of the healthcare provider. Selegiline is used to treat Parkinson's disease, in combination with levadopa-carbidopa. The nurse should instruct the client to take medication as directed and take missed doses as soon as possible, unless it is late afternoon or evening or almost time for next dose. Caution the client that taking more than the prescribed dose may increase adverse effects. Foods and beverages containing tyramine can precipitate hypertensive crisis and must be avoided. They include aged cheese, air-dried or cured meats including sausages and salamis; fava beans, tap/draft beers, Marmite concentrate, sauerkraut, soy sauce, and other soybean condiments. Improperly stored or spoiled food cause an increase in tyramine concentrations. Clients should be advised to avoid large quantities of caffeine-containing beverages, and OTC or herbal cough or cold medications. The client should be advised to change positions slowly to minimize orthostatic hypotension. Incorrect Answers: A. Muscular rigidity and drooling are signs of extrapyramidal side effects associated with antipsychotic medications such as haloperidol (Haldol) and Thorazine. They are less common with newer antipsychotic medications. Desipramine is not an antipsychotic. B. Seizures can be a sign of overdose in MAOI medications. In this setting, an overdose is unlikely. D. Many medications that act on the central nervous system have anticholinergic effects, including thirst or dry mouth. MAOI medications commonly cause dry mouth or increased thirst.

A nurse teaches a client with Cushing's disease. Which dietary requirements should the nurse include in this clients teaching? (Sata) A. Low calcium B. Low carbohydrate C. Low protein D. Low calories E. Low sodium

Answer: B, D, E. Dietary modifications need to include reduction of carbohydrates and total calories to prevent ir reduce degree of hyperglycemia. Clients are encouraged to restrict sodium intake moderately due to water retention and hypertension. Clients often have bone density loss and need more calcium

A patient diagnosed with general anxiety disorder (GAD) reports ongoing nausea and abdominal bloating. A physical examination fails to confirm a medical illness to explain these symptoms. The healthcare provider suspects these findings are a result of which of the following? A. Derealization B. Somatization C. Dysthymia D. Dissociation

Answer: B, Somatization The production of recurrent and multiple medical symptoms with no discernible organic cause.

A nurse is writing a care plan for a client, which goal is considered measurable? A. The client will resume adequate urine output B. Client will maintain adequate cardiac output C. Client will ambulate 3 times a daily D. Client will tolerate a greater protein intake.

Answer: C

Which finding is characteristic during the emergent period after a deep full thickness burn injury? Quiz link & rationales : goo.gl/1oToLC A. Blood pressure of 170/100 mm Hg B. Foul-smelling discharge from wound C. Pain at site of injury D. Urine output of 10 mL/hr

Answer: D.. One of the signs of hypovelemic shock

What r imp NCLEX tips for an aneurysm?

Avoid straining,lifting or exerting,take medication on schedule,report severe back/flank pain

Wt area of the body is the best site for applying a fentanyl patch

Best area is Chest area

Wt Drug can we give to lessen the side affects of first generation antipsychotic(phenothiazines)?

Cogentin ( benztropine ) an Anti-Parkinson medication

Best food substitute for pt with celiac disease

Rice, corn ( gluten free diet)

Selective serotonin reuptake inhibitor or SSRI What do These medications help you do ? Which in turn make you ? All SSRI can cause ____ if too much is given ? Never give as SSRI WITH what 2things ?

These medications help you keep serotonin in the system longer which in turn makes you happier😊 All SSRI can cause serotonin syndrome or serotonin overload of too much of the drug is given! Never give as SSRI WITH MAOI and ST John herb EVER

Does this mark goes (blue in back of butt or only back in pic) way after baby is grown up or it will increase and cause more problem to baby? IMP

Yes go away, normal, mangolian spot

Is heparin safe in pregnancy?

Yes, but not warfarin (Coumadin)

What is common mental health problem after age 70 and how do you educated that client about that ?

hallucinations and delusions

Paternalism

idea that a individual has right to make decision for somebody else