A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg by mouth (PO) for withdrawal symptoms.

The client begins to complain of feeling nervous and tells the nurse that her bones are itching.

Which finding should the nurse identify as a contraindication for administering the medication?

Hypertension.

Apical heart rate 72 beats/minute.

Muscle weakness.

Blood pressure 90/76 mm Hg.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D.

Choice A rationale:

Hypertension is not a contraindication for administering clonidine. In fact, clonidine is often used to treat hypertension. It works by decreasing the levels of certain chemicals in your blood, allowing your blood vessels to relax and your heart to beat more slowly and easily.

Choice B rationale:

An apical heart rate of 72 beats/minute is within the normal range (60-100 beats/minute) and would not be a contraindication for administering clonidine. Clonidine can lower heart rate, so it’s important to monitor heart rate, but a normal heart rate does not preclude its use.

Choice C rationale:

Muscle weakness is not a specific contraindication for the use of clonidine. While muscle weakness can be a side effect of many medications, it is not typically associated with clonidine. However, if a patient was experiencing severe or unusual muscle weakness, it would be important for the healthcare provider to evaluate this symptom.

Choice D rationale:

A blood pressure of 90/76 mm Hg could be a contraindication for the use of clonidine. Clonidine is a medication that is used to lower blood pressure, and if a patient’s blood pressure is already low, further lowering it could lead to symptoms such as dizziness, fainting, or even shock. Therefore, it would be important to monitor the patient’s blood pressure closely while they are taking this medication.

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Correct Answer is D

Explanation

Choice A rationale:

Concerns about parenting. While concerns about parenting are important to address during prenatal care, the initial visit focuses on gathering essential information and providing education related to pregnancy and childbirth. Knowledge about labor and delivery is crucial for the client to understand the process and make informed decisions.

Choice B rationale:

Cultural practices related to childbearing. Cultural practices related to childbearing are also essential topics to discuss during prenatal care, but they may not be the highest priority at the initial visit. Understanding the client's cultural background and beliefs is important, but providing information about pregnancy and childbirth should take precedence during the first prenatal visit.

Choice C rationale:

Complications associated with childbirth. Discussing complications associated with childbirth is important, but it may be overwhelming for a client during the initial prenatal visit. The primary focus should be on providing basic information and addressing immediate questions and concerns, with more in-depth discussions about complications occurring in subsequent visits.

Choice D rationale:

Knowledge about labor and delivery. This is the correct choice because the initial prenatal visit should include education about pregnancy, labor, and delivery. Providing the client with essential knowledge about what to expect during labor and delivery empowers her to make informed decisions and plan for her childbirth experience.

A. CP is one of the most common permanent physical disabilities in children. B. Brain damage with CP is not progressive but does have a variable course. C. Severe motor dysfunction determines the extent of successful habilitation. D. Continued development of the brain lesion determines the child's outcome.

Correct Answer is B

Explanation

Choice A rationale:

CP being one of the most common permanent physical disabilities in children is a general statement but does not directly address the mother's question about the progression of her child's impaired movements. It does not provide an explanation for the potential course of CP.

Choice B rationale:

Brain damage with CP is not progressive but does have a variable course. This response provides the best explanation to the mother's question. CP is a static neurological condition, which means that the initial brain injury that led to CP does not worsen over time. However, the functional abilities and impairments of a child with CP can vary widely and may change as the child grows and develops. Some children may improve with therapy and interventions, while others may have relatively stable impairments.

Choice C rationale:

Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.

Choice D rationale:

Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit?

Correct Answer is D

Explanation

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

After an increase in the number of suicides in a community, the nurse is developing a class for adolescents about mental health. Which type of activity should the nurse include in the teaching?

A child who weighs 55 pounds receives a prescription for cefotaxime 150 mg/kg/day intravenously in divided doses every 6 hours. How many mg should the nurse administer each day?

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?