The client who is seropositive for human immunodeficiency virus (HIV) has been taking stavudine (d4T, Zerit XR). The nurse assesses which of the following most closely while the client is taking this medication?
1. Appetite
2. Gastrointestinal function
3. Presence of paresthesia
4. Level of consciousness (LOC)
3
Rationale: Stavudine is an antiretroviral (protease inhibitor) used in the management of HIV infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy; the nurse should closely monitor the client's gait and ask the client about paresthesia. "Appetite," "gastrointestinal," and "level of consciousness (LOC)" are not a concern.
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The prescriber orders a medication q8h. The nurse enters the following times on the medication administration record (MAR): 12 AM- 6 AM- 12 PM- 6 PM
What error has occurred?
A nurse appointed to provide home care to a client feels it is not safe to visit the client on a particular day. What should the nurse do in such a situation?
A) Ignore the instincts, because the client needs assistance. B) Inform a physician and ask for assistance on the home visit. C) Inform client and family caregivers about not visiting them. D) Take assistance from a colleague when on the home visit.
The autonomic nervous system is involved in all of the following EXCEPT:
A) controls involuntary activities such as digestion B) carries messages without conscious thought C) controls speech D) has sympathetic and parasympathetic divisions
An 8-year-old girl tells the nurse that she has cancer because God is punishing her for "being bad." She shares her concern that, if she dies, she will go to hell. The nurse should interpret this as being:
a. A belief common at this age. b. A belief that forms the basis for most religions. c. Suggestive of excessive family pressure. d. Suggestive of a failure to develop a conscience.