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Questions 158

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Question 1 of 5

A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:

Correct Answer: D

Rationale: The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. Assessment of vital signs will not help to restore uterine atony, which is the priority need. Giving a prescribed oxytocic drug would be necessary if the uterus did not maintain tone with massage. Fundal massage generally restores uterine tone within a few moments and should be attempted first.

Question 2 of 5

A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:

Correct Answer: C

Rationale: There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. Benztropine is an antiparkinsonism drug frequently given to counteract extrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium).

Question 3 of 5

The nurse is caring for a client with a history of systemic lupus erythematosus. The nurse should expect the client to have:

Correct Answer: A

Rationale: Systemic lupus erythematosus causes autoimmune inflammation, commonly leading to joint pain and arthritis-like symptoms.

Question 4 of 5

Which of the following side effects is associated with androgen therapy?

Correct Answer: C

Rationale: Androgen therapy promotes male secondary sexual characteristics leading to virilization (e.g. deepened voice facial hair). Gynecomastia is associated with estrogen and increased appetite or euphoria are not typical side effects of androgens.

Question 5 of 5

A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:

Correct Answer: D

Rationale: If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.

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