The client is being treated with one of the sulfonamides. She complains to the nurse of experiencing a sore throat. What is the highest priority action on the part of the nurse?
a. Administer the medication; this is an expected side effect of the medication.
b. Call the physician; this is symptomatic of development of a superinfection.
c. Call the physician; this is symptomatic of a life-threatening anemia.
d. Hold the medication and call the pharmacist for clarification.
ANS: C
Observe the client for hematologic reaction that may lead to life-threatening anemias. Early signs are sore throat, purpura, and decreasing white blood cell and platelet counts.
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The nurse is teaching staff at a community mental health clinic about what constitutes a mental disorder. Which comment by staff indicates to the nurse the need for further teaching?
1. "Experiencing distressful symptoms may imply a mental disorder." 2. "Experiencing pain and suffering may imply a mental disorder." 3. "Being unable to function in everyday life is consistent with a mental disorder." 4. "Grieving after a loss may signal a mental disorder."
The nurse is performing a physical assessment of a male client. The nurse must assess the client's sacrococcygeal area. Which of the following positions will allow the nurse to assess this area adequately?
1. Orthopneic position 2. Semi-Fowler's position 3. Lithotomy 4. On his left side with his knees drawn up
You are the nurse working with an adolescent who has just been diagnosed with a sexually transmitted disease. In your state the provider of care has an obligation to report sexually transmitted diseases to the local health department
Your best action is which of the following? a. Explain to the adolescent that the law requires reporting of this information, which will be handled in a sensitive and appropriate manner. b. Report the information, and let the local health department deal with the adolescent, as they are trained in sensitive matters. c. Ask the parents of the adolescent to notify the local health department. d. Ask the hospital social worker to notify the local health department.
Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis?
a. Risk for Falls b. Risk for Ineffective Airway Clearance (choking) c. Risk for Poisoning d. Risk for Suffocation (drowning)