A client is admitted to the chemical dependency unit for evaluation of alcoholism. Which question is part of an alcoholism-assessment tool called the CAGE questionnaire?
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Solution
Answer B is correct. One of the questions on the CAGE assessment asks whether criticism of one’s drinking is annoying. Other questions included in this assessment tool are “Have you ever felt you should cut down on your drinking?”, “Have you felt guilty about your drinking?”, and “Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?” The answers in A, C, and D are part of the Alcohol Use Disorders Identification Test (AUDIT), so they are incorrect.
A client is to undergo insertion of an esophageal gastric balloon tube. Which instruction would the nurse include in teaching about the purpose of the device?
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Solution
Answer A is correct. An esophageal gastric balloon tube is inserted for bleeding esophageal varices by placing direct pressure and stopping the bleeding. It cannot be used to prevent fluid build-up in the peritoneal cavity, as in answer B. The bleeding is a venous backup of blood, not an arterial one, so answer C is incorrect. Sclerotherapy is done by endoscopic procedure, so answer D is incorrect.
A client recovering from a thyroidectomy tells the nurse, “I feel numbness and my face is twitching.” What is the nurse’s best initial action?
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Solution
Answer C is correct. The parathyroid gland can be inadvertently removed or injured with thyroid removal. This can cause hypocalcemia and symptoms of tetany, which requires notifying the physician. Answers A and B are ineffective ways to treat or obtain treatment for hypocalcemia. Answer D would allow the condition to progress, so it is incorrect.
Which exam is most reliable in diagnosing peptic ulcer disease?
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Solution
Answer C is correct. Although all of the tests listed can be used to diagnose an ulcer, an endoscopic exam is the only way to obtain accurate visual evidence. Answers A, B, and D are not as accurate or reliable, which makes them incorrect.
A client with diagnosed diabetes visits the clinic complaining of shakiness and tingling sensations. Which of the following questions is most important for the LPN/LVN to ask?
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Solution
Answer C is correct. The client is exhibiting symptoms of hypoglycemia. The LPN needs to gather information related to the client’s diagnosis. The questions in A, B, and D are appropriate. But the priority would be to find out the problem and treat it.
A client who had an abdominal aortic aneurysm repair is having delayed healing of the wound. Which laboratory test result would most closely correlate to this problem?
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Solution
Answer A is correct. Protein is a necessary component of wound healing. An inadequate amount of protein would correlate with the client’s wound not healing properly. Answers B, C, and D do not directly relate to wound healing, so they are incorrect.
A client with Alzheimer’s disease has been prescribed donepezil (Aricept). Which information should the nurse include when explaining about Aricept?
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Solution
Answer B is correct. A side effect of Aricept is dizziness; therefore, the client should be reminded to move slowly on rising from a lying or sitting position. Answer A is incorrect because it should be taken at bedtime, with no regard to food. Increasing the number of pills can increase the side effects, so answer C is incorrect. Another effect of the drug is bradycardia, making answer D incorrect.
A client with a femur fracture is exhibiting shortness of breath,pain upon deep breathing, and a cough that produces bloodtinged sputum. The nurse would determine that these clinical manifestations are indicative of which of the following?
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Solution
Answer B is correct. Hemoptysis is a hallmark symptom of a pulmonary embolus. This client’s fracture history and other clinical manifestation leads to this conclusion. The clinical manifestations as a group do not correlate with the diagnoses in answers A, C, and D
A client with severe anxiety has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication?
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Solution
Answer B is correct. Tremors are an extrapyramidal side effect that can occur when taking Haldol. Answers A, C, and D are not side or adverse effects of Haldol.
The physician is about to remove a chest tube. Which client instruction is appropriate?
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Solution
Answer A is correct. This procedure prevents air entrance while the chest tube is being removed. Answer B is incorrect because it requires a lack of ventilation for too long of a period and exhalation is not allowed. Answers C and D allow air to enter the thoracic cavity during removal, so they are incorrect.