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NO.1 Prior to his discharge from the hospital, a cardiac client is started on digoxin
(Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the
following statements by the client would validate an understanding of his
medication?
A. "I would notify my physician immediately if I experience nausea, vomiting, and double
vision."
B. "I could stop taking this medication when I begin to feel better."
C. "I should only take the medication if my heart rate is greater than 100 bpm."
D. "I should always take this medication with an antacid."
Answer: A
Explanatio
n:
(A) The first signs of digoxin toxicity include abdominal pain, anorexia, nausea,
vomiting, and visual disturbances. The physician should be notified if any of these
symptoms are experienced. (B) The positive inotropic effects of digoxin increase
cardiac output and result in an enhanced activity tolerance. "Feeling better" indicates
the drug is working and medication therapy must be continued.
(C) Clients should be taught to take their pulse prior to taking the digoxin. If their
pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should
be notified. (D) Antacids decrease the effectiveness of digoxin.
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NO.2
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will
teach her to:
A. Limit activities which require focusing (close vision)
B. Take more frequent naps
C. Use artificial tears
D. Wear a patch over one eye
Answer: D
Explanatio
n:
(A)
Limiting activities requiring close vision will not alleviate the discomfort of
double vision. (B)
Frequent naps may be comforting, but they will not prevent double vision. (C)
Artificial tears are necessary in the absence of a corneal reflex, but they have no
effect on diplopia.
(D)
An eye patch over either eye will eliminate the effects of double vision during the time
the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex.
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NO.3 A 24-year-old client presents to the emergency department protesting "I am God."
The nurse identifies this as a:
A. Delusion
B. Illusion
C. Hallucination
D. Conversi
on Answer:
A
Explanation
:
(A) Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external
sensory experience. (C) Hallucination is a false sensory perception involving any of the
senses. (D) Conversion is the expression of intrapsychic conflict through sensory or
motor manifestations.
NO.4 In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to
4 weeks, or
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even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is
prescribed during the first few days or weeks of an acute episode to manage severe
behavioral excitement and acute psychotic symptoms. In addition to the lithium,
which one of the following medications might the physician prescribe?
A. Diazepam (Valium)
B. Haloperidol (Haldol)
C. Sertraline (Zoloft)
D. Alprazolam
(Xanax) Answer: B
Explanation:
(A) Diazepam is an antianxiety medication and is not designed to reduce psychotic
symptoms. (B) Haloperidol is an antipsychotic medication and may be used until
the lithium takes effect. (C) Sertraline is an antidepressant and is used primarily to
reduce symptoms of depression. (D) Alprazolam is an antianxiety medication and is
not designed to reduce psychotic symptoms.
NO.5 A violent client remains in restraints for several hours. Which of the following
interventions is most appropriate while he is in restraints?
A. Give fluids if the client requests them.
B. Assess skin integrity and circulation of extremities before applying restraints
and as they are removed.
C. Measure vital signs at least every 4 hours.
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