Question

A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

Answer 1

Correct Answers:

Acetaminophen

Rationale :

🔴 Acetaminophen is the preferred analgesic for clients with a history of peptic ulcer disease (PUD) because it does not affect gastric prostaglandins or mucosal integrity.

🔴 NSAIDs such as ketorolac, ibuprofen, and aspirin inhibit cyclooxygenase-1 (COX-1), reducing protective gastric secretions and significantly increasing the risk for GI bleeding or ulcer exacerbation.

🔴 Acetaminophen is effective for mild to moderate pain, such as headaches, and is generally well tolerated with a favorable gastrointestinal safety profile.

🔴 It is the safest first-line agent when treating pain in clients with preexisting gastrointestinal conditions.

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Answer 2

Correct Answers:

"I should use a soft-bristle toothbrush to clean my teeth after meals."

Rationale :

🟠 Clients undergoing radiation therapy often develop stomatitis, which is painful inflammation of the oral mucosa.

🟠 Using a soft-bristle toothbrush reduces trauma to sensitive tissues and helps maintain oral hygiene without exacerbating pain or tissue breakdown.

🟠 Alcohol-based mouthwashes and lemon-glycerin swabs are contraindicated, as they worsen mucosal dryness and irritation.

🟠 Good oral care using non-irritating methods can help prevent secondary infections and promote comfort.

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Answer 3

Correct Answers:

Instruct the client to empty her bladder prior to the procedure.

Rationale :

🟡 A full bladder during a paracentesis increases the risk of bladder puncture, especially when accessing fluid in the lower abdomen.

🟡 Having the client empty her bladder beforehand improves access and decreases the risk of complications.

🟡 Paracentesis does not require NPO status or an overbed table for positioning, and IV boluses are not standard pre-procedure.

🟡 Proper pre-procedural preparation ensures both safety and procedural accuracy.

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Answer 4

Correct Answers:

Cheese

Rationale :

🟢 Monoamine oxidase inhibitors (MAOIs) can cause a hypertensive crisis if the client ingests foods high in tyramine, such as aged cheeses, cured meats, and fermented products.

🟢 Tyramine causes the release of norepinephrine, and MAOIs prevent its breakdown, leading to dangerously elevated blood pressure.

🟢 Clients on MAOIs must follow a strict tyramine-restricted diet to prevent adverse effects.

🟢 Cheese is one of the most commonly restricted foods and must be avoided unless specifically cleared as tyramine-free.

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Answer 5

Correct Answers:

Muscle weakness

Rationale :

🔵 Simvastatin and other statins carry a risk of myopathy and rhabdomyolysis, which can manifest as muscle weakness or pain.

🔵 This adverse effect results from muscle fiber breakdown, which may lead to renal injury if not identified early.

🔵 Clients should be taught to report unexplained muscle tenderness, cramps, or weakness, especially in the thighs or shoulders.

🔵 Timely recognition allows providers to evaluate creatine kinase (CK) levels and possibly discontinue the medication to prevent progression.

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Answer 6

Correct Answers:

Establish the responsibilities of the nurse and client.

Rationale :

🟣 The orientation phase of a therapeutic relationship is focused on building trust, establishing expectations, and clarifying roles.

🟣 It includes discussing confidentiality, session structure, and boundaries, which create a safe environment for disclosure.

🟣 More advanced actions, like identifying coping skills or problem-solving, are part of the working phase, not orientation.

🟣 Defining responsibilities early provides the foundation for therapeutic collaboration.

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Answer 7

Correct Answers:

Encourage the client to take frequent rest periods.

Rationale :

🟤 Clients experiencing manic episodes have increased activity, poor judgment, and limited need for sleep, which places them at risk for exhaustion.

🟤 Encouraging rest helps balance stimulation and conserve energy, supporting both physical health and emotional regulation.

🟤 Overstimulating environments (e.g., dayrooms) and punitive actions (e.g., removing TV privileges) may worsen symptoms.

🟤 Promoting periods of rest is a therapeutic and non-confrontational approach that aligns with the client’s current needs.

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Answer 8

Correct Answers:

Preoccupied with aging

Rationale :

⚫ Clients with narcissistic personality disorder often display an intense concern with appearance, youth, and admiration.

⚫ As they age, they may fear losing attractiveness and social status, leading to preoccupation with aging.

⚫ Unlike paranoid or obsessive-compulsive personality traits, narcissistic traits are rooted in self-image and perceived worth.

⚫ This insight helps guide assessments and support realistic self-perception goals.

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Answer 9

Correct Answers:

"The client exhibits impulsive behavior."

Rationale :

⚪ Borderline personality disorder (BPD) is characterized by emotional instability, impulsivity, and intense interpersonal relationships.

⚪ Clients may engage in risk-taking or self-harming behaviors in response to emotional distress or fear of abandonment.

⚪ Impulsivity can manifest in areas like spending, eating, or substance use, often without regard to consequences.

⚪ Recognizing impulsivity as a hallmark feature aids in risk reduction planning and therapeutic engagement.

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Answer 10

Correct Answers:

Ask the client directly what he is hearing

Rationale :

🟢 Asking the client directly about auditory hallucinations is an essential therapeutic strategy that promotes trust and assessment accuracy.

🟢 It allows the nurse to determine the content, intensity, and risk associated with the hallucinations (e.g., if they are command hallucinations that could lead to harm).

🟢 Acknowledging the experience without reinforcing the hallucination as reality allows the client to feel heard without validating delusions.

🟢 Avoiding eye contact or encouraging isolation (e.g., lying in a quiet room alone) can exacerbate symptoms by fostering disconnection and mistrust.

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QLexNursing

1 :
A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

2 :
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?

3 :
A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?

4 :
A nurse is teaching a client who has a new prescription for an MAOI. Which of the following foods is contraindicated with this medication?

5 :
A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider?

6 :
A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

7 :
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?

8 :
A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?

9 :
A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

10 :
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

QLexNursing

1 : A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

2 : 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?

3 : A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?

4 : A nurse is teaching a client who has a new prescription for an MAOI. Which of the following foods is contraindicated with this medication?

5 : A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider?

6 : A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

7 : A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?

8 : A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?

9 : A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

10 : A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

1 :
A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

2 :
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?

3 :
A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?

4 :
A nurse is teaching a client who has a new prescription for an MAOI. Which of the following foods is contraindicated with this medication?

5 :
A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider?

6 :
A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

7 :
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?

8 :
A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?

9 :
A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

10 :
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?