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The nurse is reviewing the client's prescriptions.

Exhibits

For each body system below, click to highlight the findings that indicate a serious adverse reaction. To deselect a finding, click on the finding again. Each body system may support more than 1 potential assessment finding.

Body Systems

Findings

Head, Eyes, Ears, Nose, and Throat (HEENT)

Yellowing of the eyes

Blurred vision

Dry eyes

Gastrointestinal

Abdominal pain

Hard stool

Hematologic

Increased bruising

Increased bleeding tendency

Insomnia

Genitourinary

Red/orange tint to urine

Darkening of the urine

Yellowing of the eyes

Blurred vision

Dry eyes

Abdominal pain

Hard stool

Increased bruising

Increased bleeding tendency

Insomnia

Red/orange tint to urine

Darkening of the urine

Answer and Explanation

The Correct Answer is ["A","B","D","F","G","I","J"]

Yellowing of the eyes could indicate hepatotoxicity, a serious adverse effect associated with some of the anti-tuberculosis medications, particularly rifampin.

Blurred vision could be a sign of optic neuritis, a rare but serious adverse effect associated with ethambutol.

Abdominal pain could indicate hepatitis or hepatotoxicity, which are potential adverse effects of anti-tuberculosis medications like isoniazid and rifampin.

Increased bruising could indicate thrombocytopenia, a serious adverse effect associated with some anti-tuberculosis medications, particularly rifampin.

Increased bleeding tendency could also indicate thrombocytopenia or other hematologic abnormalities.

Red/orange tint to urine could indicate rifampin-induced discoloration of bodily fluids, which is not harmful but can be alarming to patients.

Darkening of urine could also be a result of rifampin-induced discoloration. It's important to differentiate between this harmless side effect and hematuria, which could indicate a more serious issue.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Limiting intake of dairy products may not directly address stomatitis unless the client has an intolerance or allergy to dairy.
B. Using a soft-bristle toothbrush helps prevent trauma to the oral mucosa, which can exacerbate stomatitis. Gentle oral care with a soft toothbrush after meals helps maintain oral hygiene without causing further irritation.
C. Moistening lips with lemon-glycerin swabs may further irritate the oral mucosa due to the acidic nature of lemon.
D. Gargling with an alcohol-based mouthwash can exacerbate stomatitis and should be avoided due to its drying effect on oral tissues.

A. Establish a toileting schedule for the client. B. Use clothing with buttons and zippers. C. Discourage physical activity during the day. D. Engage the client in activities that increase sensory stimulation.

Correct Answer is A

Explanation

A. Setting a routine, including a toileting schedule, helps manage incontinence and reduces confusion and anxiety for a client with dementia. Regular schedules provide structure and can improve cooperation and quality of life.
B. Simplifying clothing with easy fasteners like Velcro instead of buttons and zippers can help maintain independence in dressing for a person with dementia.
C. Physical activity should be encouraged as it can help reduce agitation, improve mood, and promote better sleep patterns.
D. Excessive sensory stimulation can be overwhelming and confusing for clients with dementia; activities should be calming and familiar.

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Body Systems	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Hard stool
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Red/orange tint to urine Darkening of the urine

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is providing teaching to family members of a client who has dementia. Which of the following Instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?

A nurse is caring for a client who refuses a blood transfusion. Which of the following actions should the nurse take?

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse Identify as tertiary prevention?

A nurse is caring for a client at a clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing dropdown due to dropdown.

A nurse is updating the plan of care for a client who has amyotrophic lateral sclerosis with dysphagia. Which of the following interprofessional team members should the nurse identify as the priority to consult?

A school nurse is performing scollosis screenings. The nurse should recognize which of the following clinical manifestations as an Indication of scollosis?

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for jaundice?

A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take?