A patient with newly diagnosed diabetes mellitus is learning to recognize the symptoms of hypoglycemia. Which of the following symptoms is indicative of hypoglycemia?
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Solution
Confusion.
Hypoglycemia in diabetes mellitus causes confusion, indicating the need for carbohydrates. Polydipsia, blurred vision, and polyphagia are symptoms of hyperglycemia.
A patient at a mental health clinic is taking Haldol (haloperidol) for treatment of schizophrenia. She calls the clinic to report abnormal movements of her face and tongue. The nurse concludes that the patient is experiencing which of the following symptoms:
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Solution
Tardive dyskinesia.
Abnormal facial movements and tongue protrusion in a patient taking haloperidol is most likely due to tardive dyskinesia, an adverse reaction to the antipsychotic. Depression may occur along with schizophrenia and would be characterized by such symptoms as loss of affect, appetite and/or sleep changes, and anhedonia. These depressive changes and lack of volition are part of the negative symptoms of schizophrenia. Psychotic hallucinations may be visual or auditory but do not include abnormal movements.
A mother calls the clinic to report that her son has recently started medication to treat attention deficit/hyperactivity disorder (ADHD). The mother fears her son is experiencing side effects of the medicine. Which of the following side effects are typically related to medications used for ADHD? Note: More than one answer may be correct:
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Solution
A, B, and D
ADHD in children is frequently treated with CNS stimulant medications, which increase focus and improve concentration. Children often experience insomnia, agitation, and decreased appetite. Sleepiness is not a side effect of stimulants.
A patient is brought to the emergency department after a bee sting. The family reports a history of severe allergic reaction, and the patient appears to have some oral swelling. Which of the following is the most urgent nursing action?
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Solution
Maintain a patent airway.
The patient may be experiencing an anaphylactic reaction. The most urgent action is to maintain an airway, particularly with visible oral swelling, followed by the administration of epinephrine by subcutaneous injection. The physician will see the patient as soon as possible with the above actions underway. Oral diphenhydramine is indicated for mild allergic reactions and is not appropriate for anaphylaxis.
A nurse is counseling patients at a health clinic on the importance of immunizations. Which of the following information is the most accurate regarding immunizations?
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Solution
Immunization provides acquired immunity from some specific diseases.
Immunization is available for the prevention of some, but not all, specific diseases. This type of immunity is “acquired” by causing antibodies to form in response to a specific pathogen. Natural immunity is present at birth because the infant acquires maternal antibodies Immunization, like all medication, cannot be risk-free and should be considered based on the risk of the disease in question.
A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient?
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Solution
Change gloves immediately after use.v
The neutropenic patient is at risk of infection. Changing gloves immediately after use protects patients from contamination with organisms picked up on hospital surfaces. This contamination can have serious consequences for an immunocompromised patient. Changing the respiratory mask is desirable, but not nearly as urgent as changing gloves. Minimizing contact and conversation are not necessary and may cause nursing staff to miss changes in the patient’s symptoms or condition.
A nurse in the emergency department assesses a patient who has been taking long-term corticosteroids to treat renal disease. Which of the following is a typical side effect of corticosteroid treatment? Note: More than one answer may be correct.
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Solution
A, B, and D
Side effects of corticosteroids include weight gain, fluid retention with hypertension, Cushingoid features, a low serum albumin, and suppressed inflammatory response. Patients are encouraged to eat a diet high in protein, vitamins, and minerals and low in sodium. Corticosteroids cause hypernatremia, not hyponatremia.
A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention?
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Solution
Observe for evidence of spontaneous bleeding.
Platelet counts under 30,000/microliter may cause spontaneous petechiae and bruising, particularly in the extremities. When the count falls below 15,000, spontaneous bleeding into the brain and internal organs may occur. Headaches may be a sign and should be watched for. Aspirin disables platelets and should never be used in the presence of thrombocytopenia. Thrombocytopenia does not compromise immunity, and there is no reason to limit visitors as long as any physical trauma is prevented.
A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply.
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Solution
B, C, and D
Polycythemia vera is a condition in which the bone marrow produces too many red blood cells. This causes an increase in hematocrit and viscosity of the blood. Patients can experience headaches, dizziness, and visual disturbances. Cardiovascular effects include increased blood pressure and delayed clotting time. Weight loss is not a manifestation of polycythemia vera.
A patient who has received chemotherapy for cancer treatment is given an injection of Epoetin. Which of the following should reflect the findings in a complete blood count (CBC) drawn several days later?
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Solution
An increase in hematocrit.
Epoetin is a form of erythropoietin, which stimulates the production of red blood cells, causing an increase in hematocrit. Epoetin is given to patients who are anemic, often as a result of chemotherapy treatment. Epoetin has no effect on neutrophils, platelets, or serum iron.