A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings?
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Solution
These side effects are common and should subside in a few days
Option A: Nausea, metallic taste, and fine hand tremors are common side effects that usually subside within days.
A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breastfeed the infants. Which of the following is based on sound rationale?
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Solution
“Nursing will help contract the uterus and reduce your risk of bleeding.”
Option A: Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage.
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
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Solution
Shallow respirations
Option C: A.L.S. is a chronic progressive disease that involves degeneration of the anterior horn of the spinal cord as well as the corticospinal tracts. When the intercostal muscles and diaphragm become involved, the respirations become shallow and coughing is ineffective.
A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
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Solution
Oral contraceptives should not be used by smokers
Option B: The use of oral contraceptives in a pregnant woman who smokes increases her risk of cardiovascular problems, such as thromboembolic disorders.
Following mitral valve replacement surgery, a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mgm of Lidocaine/minute?
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Solution
60 microdrops/minute
2 gm=2000 mgm
2000 mgm/500 cc = 4 mgm/x cc
2000x = 2000
x= 2000/2000 = 1 cc of IV solution/minute
CC x 60 microdrops = 60 microdrops/minute
A mother brings her 26-month-old to the well-child clinic. She expresses frustration and anger due to her child’s constantly saying “no” and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
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Solution
Independence
Option C: In Erikson’s theory of development, toddlers struggle to assert independence. They often use the word “no” even when they mean yes. This stage is called autonomy versus shame and doubt.
A 16-year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause of suicide in adolescents is
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Solution
Feelings of alienation or isolation
Option D: The isolation may occur gradually resulting in a loss of all meaningful social contacts. Isolation can be self-imposed or can occur as a result of the inability to express feelings. At this stage of development, it is important to achieve a sense of identity and peer acceptance.
Which of the following measures would be appropriate for the nurse to teach the parent of a nine-month-old infant about diaper dermatitis?
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Solution
Discontinue a new food that was added to the infant’s diet just prior to the rash
Option D: The addition of new foods to the infant’s diet may be a cause of diaper dermatitis.
An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
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Solution
Encourage her to talk about her view of herself
Option C: To an adolescent, body image is very important. The nurse must acknowledge this before assessment and teaching.
Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?
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Solution
“What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?”
Option B: This response encourages the client to get in touch with their feelings and utilize problem-solving steps to reduce guilt feelings.