Nursing Elites

1. The client is taking Antabuse and should avoid eating foods that may trigger a disulfiram reaction. The nurse should instruct the client to avoid:

• A. Peanuts, dates, raisins
• B. Figs, chocolate, eggplant
• C. Pickles, salad with vinaigrette dressing, beef
• D. Milk, cottage cheese, ice cream

Correct answer: C

Rationale: The client taking Antabuse should avoid foods that contain alcohol or vinegar as they can trigger a disulfiram reaction. Pickles and vinaigrette dressing often contain vinegar, which the client should avoid. Beef is safe to consume. Choices A, B, and D do not contain alcohol or vinegar, so they are allowed for the client taking Antabuse.

2. Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?

• A. Dizziness and orthostatic hypotension.
• B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
• C. Drowsiness, lethargy, and fatigue.
• D. Neuropathy and tingling in the extremities.

Correct answer: B

Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.

3. The manic client has just interrupted the group session with the counselor for the 4th time, explaining that she already knows this information on 'dealing with others when you are down' and constantly gets up and goes to the front. What should the nurse do at this time?

• A. Engage the client to walk with you to make another pot of coffee
• B. Ask the client to reflect on their behavior to determine if it is appropriate
• C. Ask the group to tell the client how they feel when she interrupts
• D. Instruct the client to perform jumping jacks and count aloud to get rid of some energy

Correct answer: A

Rationale: In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (Choice B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (Choice C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (Choice D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.

4. High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by:

• A. the inability of the kidneys to excrete the drug metabolites.
• B. rapid cell catabolism.
• C. toxic effects of the prophylactic antibiotics that are given concurrently.
• D. the altered blood pH from the acidic nature of the drugs.

Correct answer: B

Rationale: The correct answer is 'rapid cell catabolism.' During chemotherapy, rapid cell destruction occurs, leading to an increase in uric acid levels as a byproduct of cell breakdown. High uric acid levels are primarily a result of the rapid breakdown of cells during chemotherapy, not due to the kidneys' inability to excrete drug metabolites (Choice A). The prophylactic antibiotics given concurrently do not directly cause high uric acid levels (Choice C). The altered blood pH from the acidic nature of the drugs (Choice D) is not a direct cause of elevated uric acid levels; the main mechanism is the rapid cell catabolism that occurs during chemotherapy.

5. A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).

• A. Weight gain
• B. Fatigue
• C. Bloody sputum
• D. Diaphoresis during sleep

Correct answer: A

Rationale: The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.

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