The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions,which include:
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Solution
Answer B is correct. An adverse reaction to Cognex (tacrine) is drug-induced hepatitis. The nurse should monitor the client for signs of jaundice. Answers A, C, and D are incorrect because they are not associated with the use of Cognex (tacrine).
When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
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Solution
Answer A is correct. Following extracorporeal lithotripsy, the urine will appear cherry red in color but will gradually change to clear urine. Answer B is incorrect because the urine will be red, not orange. Answer C is incorrect because the urine will be not be dark red or cloudy in appearance. Answer D is incorrect because it describes the urinary output of the client with acute glomerulonephritis.
The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately?
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Solution
Answer B is correct. Coolness and discoloration of the reimplanted digits indicates compromised circulation, which should be reported immediately to the physician. The temperature should be monitored, but the client would receive antibiotics to prevent infection; therefore, answer A is incorrect. Answers C and D are expected following amputation and reimplantation; therefore, they are incorrect.
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
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Solution
Answer D is correct. Tucking a disposable diaper at the perineal opening will help prevent soiling of the cast by urine and stool. Answer A is incorrect because the head of the bed should be elevated. Answer B is incorrect because the child can place the crayons beneath the cast, causing pressure areas to develop. Answer C is incorrect because the child does not need high-calorie foods that would cause weight gain while she is immobilized by the cast.
A client with schizophrenia is receiving depot injections of Haldol Deconate (haloperidol decanoate). The client should be told to return for his next injection in:
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Solution
Answer C is correct. Depot injections of Haldol are administered every 4 weeks. Answers A and B are incorrect because the medication is still in the client’s system. Answer D is incorrect because the medication has been eliminated from the client’s system, which allows the symptoms of schizophrenia to return.
The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:
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Solution
Answer A is correct. No more than 1mL should be given in the vastus lateralis of the infant. Answers B, C, and D are incorrect because the dorsogluteal and ventrogluteal muscles are not used for injections in the infant.
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
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Solution
Answer D is correct. The nurse or parent should use a cupped hand when performing chest percussion. Answer A is incorrect because the hand should be cupped. Answer B is incorrect because the child’s position should be changed every 5–10 minutes and the whole session should be limited to 20 minutes. Answer C is incorrect because chest percussion should be done before meals.
Which of the following pediatric clients is at greatest risk for latex allergy?
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Solution
Answer A is correct. The child with myelomenigocele is at greatest risk for the development of latex allergy because of repeated exposure to latex products during surgery and from numerous urinary catheterizations. Answers B, C, and D are much less likely to be exposed to latex; therefore, they are incorrect.
At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:
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Solution
Answer C is correct. Most infants begin nocturnal sleep lasting 9–11 hours by 3–4 months of age. Answers A and B are incorrect because the infant is still waking for nighttime feedings. Answer D is incorrect because it does not answer the question.
The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
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Solution
Answer B is correct. The nurse can help ready the child with cerebral palsy for speech therapy by providing activities that help the child develop tongue control. Most children with cerebral palsy have visual and auditory difficulties that require glasses or hearing devices rather than rehabilitative training; therefore, answers A and C are incorrect. Answer D is incorrect because video games are not appropriate for the age or developmental level of the child with cerebral palsy.