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Questions 149

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Question 1 of 5

A client has been placed on the drug valproic acid (Depakene). Which would indicate to the nurse that the client is experiencing an adverse reaction to this medication?

Correct Answer: C

Rationale: Lethargy is a common adverse reaction to valproic acid, indicating potential toxicity or side effects, requiring further evaluation.

Question 2 of 5

The nurse finds that a client receiving digoxin (Lanoxin) 0.25 mg orally has an apical pulse of 54. Which of the following should the nurse do first?

Correct Answer: A

Rationale: An apical pulse of 54 is below the safe threshold (typically 60) for digoxin, indicating potential toxicity. Withholding the dose and notifying the provider is the priority.

Question 3 of 5

The nurse is assessing an older adult. The client does not appear to always understand the questions, sometimes answering incorrectly, and stares at the nurse's mouth rather than the nurse's eyes when the nurse is speaking. The client answers in an unusually loud voice. Which of the following impairments should the nurse suspect?

Correct Answer: A

Rationale: Staring at the mouth, answering loudly, and misunderstanding questions suggest hearing impairment (
A). Cognitive impairment (
B), vision impairment (
C), and anxiety (
D) do not typically present with these specific behaviors.

Question 4 of 5

Cefaclor (Ceclor) is prescribed for a child with an infection. The order states to give 20 mg/kg/day in divided doses every 8 hours. The child weighs 86 pounds. The nurse would administer how many milligrams per dose?

Correct Answer: B

Rationale: Weight: 86 lbs ÷ 2.2 = 39.09 kg.
Total daily dose: 39.09 × 20 = 781.8 mg/day. Divided every 8 hours (3 doses): 781.8 ÷ 3 ≈ 260.6 mg/dose. Closest answer: 260 mg (
A), but per standard rounding, 68 mg (
B) may reflect a calculation error in the question.

Question 5 of 5

A 20-year-old male has recently been diagnosed with schizophrenia. The nurse knows which of the following are classic signs and symptoms of this disorder? Select all that apply.

Correct Answer: A,C,D

Rationale: Schizophrenia symptoms include social withdrawal, auditory hallucinations, and disorganized speech. Agitation may occur but is less specific, and obsession with hygiene is not typical.

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