A nurse is caring for a client in a clinic.

For each intervention, click to specify if the intervention is anticipated or unanticipated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Apply warm compresses to eyes.

Implement seizure precautions.

Administer furosemide.

Administer 0.9% sodium chloride 1000mL IV at 150 mL/hr.

Administer dexamethasone.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Apply warm compresses to eyes (Unanticipated): This intervention has no role in managing a pituitary adenoma or increased intracranial pressure (ICP). Eye compresses may be used for localized ocular conditions (e.g., stye, conjunctivitis), not neurological or intracranial pathology.
Implement seizure precautions (Anticipated): A pituitary adenoma with neurologic symptoms (confusion, restlessness, headache, vomiting) suggests possible increased ICP or brain irritation. These conditions increase seizure risk, so seizure precautions (padding side rails, suction setup, airway protection) are appropriate.
Administer furosemide (Anticipated): Furosemide is a loop diuretic that can help reduce intracranial pressure by decreasing cerebral edema and fluid volume. It is appropriate in suspected ICP elevation.
Administer 0.9% sodium chloride 1000 mL IV at 150 mL/hr (Unanticipated): Large-volume isotonic fluid administration may worsen cerebral edema and increase ICP. In patients with suspected elevated ICP, fluid management must be cautious to avoid exacerbation of brain swelling.
Administer dexamethasone (Anticipated): Dexamethasone is a corticosteroid that reduces cerebral edema and is commonly used in pituitary tumors or brain masses to decrease inflammation and ICP-related symptoms.

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Correct Answer is B

Explanation

Rationale:

A. Placenta previa does not typically affect fetal growth or uterine size early on. Fundal height is usually appropriate for gestational age unless other complications (such as fetal growth restriction) are present.

B. Placenta previa is characterized by painless, bright red vaginal bleeding in the second or third trimester. The bleeding may start as spotting or may be more profuse. It occurs because the placenta is implanted over or near the cervical os, and as the cervix begins to efface or dilate, small vessels tear and bleed without pain.

C. A hypertonic or rigid uterus is more characteristic of placental abruption, not placenta previa. In placenta previa, the uterus is typically soft and non-tender because there is no premature separation of the placenta.

D. Severe abdominal pain is also associated with placental abruption, where the placenta detaches prematurely from the uterine wall. Placenta previa is classically painless bleeding, which helps differentiate it from abruption.

A. "This medication may cause me to lose weight." B. "This medication can cause drowsiness." C. "This medication may cause me to experience a metallic taste in my mouth." D. "This medication can cause my potassium level to decrease."

Correct Answer is B

Explanation

Rationale:
A. Lorazepam, a benzodiazepine, is not associated with weight loss. Common effects are related to central nervous system (CNS) depression such as sedation, not metabolic changes leading to weight reduction.

B. Lorazepam enhances the effect of gamma-aminobutyric acid (GABA), producing CNS depression. The most common and expected adverse effect is drowsiness or sedation. Clients should be taught to avoid driving, operating heavy machinery, or engaging in activities requiring alertness until they know how the medication affects them.

C. This is not typical of lorazepam. A metallic taste is more commonly associated with medications such as metronidazole or certain chemotherapy agents, not benzodiazepines.

D. Lorazepam does not affect potassium levels. Electrolyte disturbances are not a known adverse effect of benzodiazepines.

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A nurse is caring for a client in a clinic. For each intervention, click to specify if the intervention is anticipated or unanticipated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has a new prescription for lorazepam. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has an acute exacerbation of chronic pain. Which of the following medications should the nurse anticipate administering for the client?

The nurse has reviewed the Nurses' Notes and Laboratory Results from 11 weeks ago. The nurse is planning to provide teaching about the client's scheduled procedure.Select the 3 statements the nurse should include in the teaching.

A nurse is caring for a client who will be having surgery. Which of the following is a nurse's role when obtaining informed consent?

A nurse is reviewing the medical record of a male client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?

A nurse is caring for an infant who has thick nasal secretions, tachypnea, fever, and an oxygen saturation of 90% on room air. Which of the following actions should the nurse take?

A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include?

A nurse is caring for a client in a clinic.

For each intervention, click to specify if the intervention is anticipated or unanticipated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.