A patient with a history of heart failure is prescribed lisinopril for blood pressure management. Which adverse effect is most commonly associated with lisinopril therapy?

Correct Answer: C

Rationale: Dry cough is the most commonly reported adverse effect associated with lisinopril therapy. Lisinopril is an ACE inhibitor, and the mechanism behind the cough is not completely understood but is thought to be related to the accumulation of bradykinin and substance P. This annoying dry cough can be a persistent issue for some patients on lisinopril, and it typically resolves once the medication is discontinued. Patients who experience this side effect should not ignore it and should consult their healthcare provider for further evaluation and possible alternative medication options. Hyperkalemia, hypertension, and bradycardia are not commonly associated adverse effects of lisinopril therapy.

Correct Answer: A

Rationale: In a pregnant woman presenting with severe abdominal pain, syncope, signs of hypovolemic shock, and gestational age of 6 weeks, the most likely cause is an ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, commonly in the fallopian tube. As the pregnancy grows and the tube stretches, it can lead to rupture, causing severe abdominal pain, internal bleeding, and signs of shock. This is a life-threatening emergency that requires prompt diagnosis and management. It is important to consider ectopic pregnancy in any pregnant woman presenting with abdominal pain and signs of shock, especially in the first trimester.

Correct Answer: C

Rationale: The first action the nurse should take when a patient post-thyroidectomy develops signs of hypocalcemia is to assess the patient's calcium level. By assessing the patient's calcium level through laboratory testing, the nurse can confirm the presence of hypocalcemia and determine the severity of the condition. This information will guide further interventions, such as administering calcium supplements or notifying the healthcare provider for additional management. It is important to confirm the diagnosis before proceeding with treatment to ensure appropriate and safe care for the patient.

Correct Answer: A

Rationale: The presentation described is characteristic of acute angle-closure glaucoma. This condition typically presents with sudden-onset severe eye pain, headache, nausea, and vomiting. On examination, the affected eye may appear red due to conjunctival injection, and there may be a steamy cornea due to corneal edema. The mid-dilated, non-reactive pupil is a key finding in angle-closure glaucoma, as the iris bombe (forward movement of the peripheral iris) blocks the drainage angle, leading to increased intraocular pressure. If left untreated, acute angle-closure glaucoma can result in irreversible vision loss. Immediate intervention is crucial to lower the intraocular pressure and prevent further damage to the optic nerve. Prompt referral to an ophthalmologist for definitive treatment is necessary in cases of suspected acute angle-closure glaucoma.

Correct Answer: B

Rationale: Magnesium sulfate is used to prevent eclampsia, but it can lead to toxicity if levels become too high. One common sign of magnesium toxicity is increased deep tendon reflexes, also known as hyperreflexia. This occurs because magnesium is a muscle relaxant, and elevated levels can lead to over-relaxation of muscles, causing an exaggerated reflex response. Other signs of magnesium toxicity include respiratory depression, decreased urine output, and cardiac arrest. Therefore, in a woman receiving intravenous magnesium sulfate during labor, an increase in deep tendon reflexes would indicate potential toxicity and require immediate intervention.

Correct Answer: C

Rationale: When a nurse discovers a discrepancy between the medication order and the patient's medication record, the priority action is to verify the medication order with the prescriber to ensure accuracy and patient safety. Administering the medication without clarification can put the patient at risk. Documenting the discrepancy and informing the charge nurse is important, but it should not delay verifying the order with the prescriber. Contacting the pharmacy for clarification may be necessary in some cases, but the immediate action should be to confirm the prescription with the prescriber to prevent errors and ensure the patient receives the correct medication.

Correct Answer: A

Rationale: Following total hip arthroplasty (THA), patients are at an increased risk of developing deep vein thrombosis (DVT) due to factors such as immobility, surgery-related vascular damage, and hypercoagulability. DVT refers to the formation of blood clots in the deep veins, typically in the lower extremities. These clots can break loose and travel to the lungs, causing a potentially life-threatening condition called pulmonary embolism (PE). Therefore, monitoring for signs and symptoms of DVT is crucial in the immediate postoperative period to promptly detect and prevent the development of complications such as PE. Common signs of DVT include leg swelling, pain, warmth, and redness. Additionally, healthcare providers may employ preventive measures such as early ambulation, compression stockings, and anticoagulant therapy to reduce the risk of DVT post-THA surgery.

Correct Answer: D

Rationale: Cooking foods in a variety that includes meat, dairy products, and beans demonstrates a positive coping index for the family in addressing the protein deficiency and malnutrition in their children. This behavior shows the family's understanding and effort to provide diverse sources of protein, which is essential for addressing protein deficiency. By including different protein-rich foods in their meals, the family is actively working towards improving the nutritional status of their children. This approach aligns with the goal of health education to change knowledge, attitudes, and practices to enhance individual, family, and community health.

Correct Answer: C

Rationale: Assessing the patient's airway is the first priority when admitting injured patients. A clear airway is crucial for effective breathing. If the airway is obstructed, the patient will not be able to breathe properly, leading to serious consequences. Therefore, ensuring a patent airway takes precedence over assessing breathing, circulation, or vital signs. Once the airway is secured, the emergency team can proceed with assessing breathing, circulation, and vital signs in order to provide appropriate treatment and care.