Nursing Elites

1. A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?

• A. Use the Wong-Baker Faces pain rating scale
• B. Assess vital signs to gauge pain severity
• C. Ask the client to describe the pain
• D. Offer a 1-10 pain scale

Correct answer: C

Rationale: Asking the client to describe the pain is the most appropriate approach to assess the quality of pain. It provides valuable qualitative information that aids in understanding the nature, cause, and potential management strategies for the headache. While pain rating scales like the Wong-Baker Faces scale and using vital signs can help quantify pain severity, they do not offer specific descriptive details that can give insights into the type and characteristics of the pain experienced by the client.

2. 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 antiparkinsonian drugs.

Correct answer: A

Rationale: Corrected Question: Monitoring blood pressure in clients receiving antipsychotic drugs is crucial because orthostatic hypotension is a common side effect. Orthostatic hypotension can lead to a sudden drop in blood pressure upon standing, increasing the risk of falls and related injuries. Therefore, regular blood pressure monitoring helps healthcare providers detect and manage this potential side effect. Incorrect Choices Rationale: - Choice B is incorrect because while antipsychotic drugs can have various side effects, causing elevated blood pressure is not a common effect associated with them. - Choice C is unrelated to blood pressure monitoring in clients receiving antipsychotic drugs. Monitoring blood pressure in this context aims to detect and manage side effects of the medication, not to assess sodium intake. - Choice D is incorrect as monitoring blood pressure in clients receiving antipsychotic drugs is primarily aimed at detecting orthostatic hypotension, not as an indicator for instituting antiparkinsonian drugs.

3. A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which intervention should the nurse implement?

• A. Encourage the client to eat foods rich in potassium
• B. Administer a potassium-sparing diuretic
• C. Administer a potassium-binding medication
• D. Hold all medications containing potassium

Correct answer: C

Rationale: A potassium level of 6.2 mEq/L indicates hyperkalemia, which is dangerous and requires immediate treatment. Administering a potassium-binding medication will help lower potassium levels and prevent life-threatening complications.

4. A client with hypothyroidism is experiencing severe lethargy and cold intolerance. What action should the nurse take?

• A. Increase the dose of levothyroxine.
• B. Administer a PRN dose of antipyretic medication.
• C. Provide a warm blanket and increase the room temperature.
• D. Increase the client's fluid intake to avoid dehydration.

Correct answer: A

Rationale: The correct answer is to increase the dose of levothyroxine. In hypothyroidism, the body does not produce enough thyroid hormone, leading to symptoms like lethargy and cold intolerance. Increasing the dose of levothyroxine, which is a synthetic thyroid hormone replacement, helps correct the deficiency and alleviates the symptoms. Choice B, administering antipyretic medication, is incorrect as antipyretics are used to reduce fever, not treat hypothyroidism symptoms. Choice C, providing a warm blanket and increasing room temperature, may provide temporary comfort but does not address the underlying hormonal deficiency. Choice D, increasing fluid intake, is important for overall health but does not directly address the symptoms of hypothyroidism.

5. A client with anemia is prescribed iron supplements. What teaching should the nurse provide?

• A. Take iron supplements with meals to prevent stomach upset.
• B. Take iron supplements with milk to improve absorption.
• C. Expect black, tarry stools as a side effect of iron supplements.
• D. Take iron supplements with vitamin C to improve absorption.

Correct answer: D

Rationale: The correct answer is D: Take iron supplements with vitamin C to improve absorption. Vitamin C enhances iron uptake, making it more bioavailable for the body. It is essential to avoid taking iron supplements with milk (choice B) as calcium-rich foods can hinder iron absorption. Taking iron supplements with meals (choice A) can help reduce stomach upset, but the optimal way to enhance absorption is with vitamin C. Black, tarry stools (choice C) are not a typical side effect of iron supplements and should be reported to the healthcare provider.

Similar Questions