Question

Phenytoin (Dilantin) suspension 200 mg is prescribed for a client with epilepsy. The suspension contains 125 mg/5 ml. How much solution should the nurse administer? Record your answer using a whole number.

Answer 1

Correct Answers:

8

Rationale :

🔹To determine how much phenytoin solution to administer, use the formula: Desired dose ÷ Concentration = Volume to administer. 🔹In this case, the desired dose is 200 mg. The concentration is 125 mg per 5 mL. 200 mg ÷ 125 mg gives 1.6 × 5 mL, resulting in 8 mL. 🔹This calculation ensures that the nurse delivers the correct dose to the client, allowing for effective management of epilepsy.

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Answer 2

Correct Answers:

Cardiovascular disease
Diuretic use

Rationale :

✅ Gout occurs due to an excess of uric acid in the blood, which forms crystals that deposit in joints. ✅ Risk factors include cardiovascular disease, which often coexists with conditions that elevate uric acid levels, and the use of diuretics, which can impair renal excretion of uric acid. ✅Depression and deep sleep deprivation, while they may affect overall health, are not specific risk factors for gout.

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Answer 3

Correct Answers:

Comfort

Rationale :

✅The primary concern when caring for a client with rheumatoid arthritis (RA) is ensuring their comfort. ✅RA causes joint pain and inflammation, and the pain can significantly limit mobility and quality of life. ✅While education, motivation, and surgical interventions may be part of the treatment plan, the immediate priority is managing pain and improving comfort to help the client function in daily life.

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Answer 4

Correct Answers:

I will limit my alcohol intake

Rationale :

✅Alcohol consumption can increase uric acid production, which exacerbates gout attacks. It is essential for clients with gout to limit alcohol intake. ✅A high-purine diet, taking aspirin, and low fluid intake would contribute to worsening gout symptoms. Proper fluid intake and prescribed medications are key to managing the condition effectively.

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Answer 5

Correct Answers:

Candidiasis

Rationale :

💎Candidiasis, a fungal infection, is a common complication in clients with AIDS due to their weakened immune systems. 💎A significantly low CD4 T-cell count makes clients more susceptible to opportunistic infections like candidiasis, which often affects the oral cavity. 💎Other conditions like xerostomia, halitosis, and gingivitis are not as strongly linked to AIDS as candidiasis

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Answer 6

Correct Answers:

You should place a magnet over the implantable device when you feel an aura occurring

Rationale :

✅ A vagal nerve stimulator (VNS) is used to help control seizures, and it can be activated by placing a magnet over the device during an aura, which is a warning sign that a seizure is about to occur. ✅This preemptive action can help stop or reduce the severity of the seizure. ✅The use of a microwave, CT scans with contrast, or a burst catheter for pain are not primary concerns related to VNS use.

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Answer 7

Correct Answers:

Exercise

Rationale :

✅ Systemic lupus erythematosus (SLE) is an autoimmune disease that can be exacerbated by factors like sunlight, infection, and certain medications. ✅ Exercise, on the other hand, is typically encouraged as it helps with joint mobility and reduces fatigue, unless the client is in an acute flare-up. ✅ The client should avoid sunlight exposure, which can trigger or worsen symptoms of SLE.

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Answer 8

Correct Answers:

Loosen the patient's clothing
Ease the patient to the floor it standing
Provide privacy

Rationale :

✔️Loosen the patient's clothing. Tight clothing, particularly around the neck or chest, can restrict airflow and exacerbate the risk of injury or respiratory distress during a seizure. Loosening the clothing ensures the client has optimal airflow and is not at risk of further harm. It is important to create a safe environment for the client during a seizure. ✔️Ease the patient to the floor if standing: If the client is standing, they are at risk of falling, which could result in serious injury. Easing the patient to the floor helps protect them from harm. The nurse should do this gently to avoid additional trauma, such as a head injury, while the client is unconscious or having muscle spasms. ✔️Provide privacy: Seizures can be distressing for the client, and clients may feel embarrassed if others are watching. Providing privacy helps maintain the client's dignity and reduces the likelihood of emotional distress after the seizure ends. This also minimizes the chance of bystanders interfering with the nurse's care.

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Answer 9

Correct Answers:

Coughing and deep breathing and hydration maintenance

Rationale :

✔️️️️ The primary intervention for a client with ineffective airway clearance due to HIV-related pneumonia is promoting coughing and deep breathing. ✔️ These techniques help the client clear mucus from the lungs, which is especially important in an immunocompromised client with pneumonia. ✔️Hydration is key as it helps thin secretions, making them easier to expectorate. ✔️These interventions reduce the risk of complications like atelectasis and promote recovery. ✔️ Elevating the head of the bed and supplemental oxygen are supportive but secondary to clearing the airway.

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Answer 10

Correct Answers:

Serum creatinine

Rationale :

💎Serum creatinine is the most accurate marker for assessing kidney function in clients with systemic lupus erythematosus (SLE), as it is a waste product produced by muscle metabolism and excreted by the kidneys. 💎 Elevated serum creatinine levels indicate impaired renal function. While BUN and urine-specific gravity provide additional insights, they are less specific than creatinine. 💎 Creatinine offers a clearer and more direct indication of renal health, particularly when monitoring for lupus-related kidney issues.

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RN Medsurg(HFC)-nurs221A

No.

1 : Phenytoin (Dilantin) suspension 200 mg is prescribed for a client with epilepsy. The suspension contains 125 mg/5 ml. How much solution should the nurse administer? Record your answer using a whole number.

2 : A nurse is discussing gout with a patient who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? Select all that apply.

3 : What is the nurse's primary consideration when caring for a client with rheumatoid arthritis?

4 : A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

5 : A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4 T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

6 : A nurse is completing discharge teaching to a patient who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching?

7 : A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

8 : The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply.)

9 : What intervention should the nurse identify as a priority for a client with a nursing diagnosis of ineffective airway clearance related to HIV-related pneumonia?

10 : A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?

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