Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol.
For which of the following adverse effects should the nurse monitor?
A. Headache.
Headache is a common adverse effect of disulfiram when alcohol is consumed. It is part of the adverse reaction created by the drug to deter individuals from drinking. While headache is a known symptom, tinnitus is a more specific and distinctive adverse effect associated with disulfiram use.
B. Hypertension.
Hypertension is not a common adverse effect of disulfiram. Disulfiram does not directly impact blood pressure. Its primary action is to cause an adverse reaction when alcohol is consumed.
C. Tinnitus.
Tinnitus (ringing in the ears) is a known adverse effect of disulfiram when alcohol is ingested. Disulfiram inhibits the breakdown of acetaldehyde, leading to an accumulation of this toxic substance in the body. Tinnitus is one of the symptoms of this toxic reaction and is a significant concern in individuals taking disulfiram for alcohol use disorder.
D. Insomnia.
Insomnia is not a common adverse effect of disulfiram. Disulfiram works by creating an unpleasant reaction when alcohol is consumed, which deters individuals from drinking. This reaction does not typically manifest as insomnia.
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Full Explanation
Choice A rationale:
Headache is a common adverse effect of disulfiram when alcohol is consumed. It is part of the adverse reaction created by the drug to deter individuals from drinking. While headache is a known symptom, tinnitus is a more specific and distinctive adverse effect associated with disulfiram use.
Choice B rationale:
Hypertension is not a common adverse effect of disulfiram. Disulfiram does not directly impact blood pressure. Its primary action is to cause an adverse reaction when alcohol is consumed.
Choice C rationale:
Tinnitus (ringing in the ears) is a known adverse effect of disulfiram when alcohol is ingested. Disulfiram inhibits the breakdown of acetaldehyde, leading to an accumulation of this toxic substance in the body. Tinnitus is one of the symptoms of this toxic reaction and is a significant concern in individuals taking disulfiram for alcohol use disorder.
Choice D rationale:
Insomnia is not a common adverse effect of disulfiram. Disulfiram works by creating an unpleasant reaction when alcohol is consumed, which deters individuals from drinking. This reaction does not typically manifest as insomnia.
Similar Questions
A nurse is assessing a client who is taking digoxin to treat chronic heart failure.
Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?
A. Hearing loss.
Hearing loss is not a typical sign of digoxin toxicity. Digoxin toxicity primarily affects the visual system, leading to disturbances such as blurred or yellow-tinted vision. It can also cause various cardiac symptoms due to its effects on heart rhythm and contractility. Hearing loss is not a recognized symptom of digoxin toxicity.
B. Tachycardia.
Tachycardia (fast heart rate) can be a sign of digoxin toxicity. Digoxin can cause arrhythmias and alter heart rate, which may lead to tachycardia. While this is a possible symptom, it is not as specific as other manifestations, such as visual disturbances.
C. Blurred vision.
Blurred vision is a hallmark sign of digoxin toxicity. Digoxin can cause disturbances in color vision, such as seeing yellow or green halos around objects. Blurred vision is a significant indicator of digoxin toxicity and requires prompt medical attention.
D. Insomnia.
Insomnia is not a recognized symptom of digoxin toxicity. Digoxin toxicity primarily affects the cardiovascular and visual systems, leading to symptoms related to heart rhythm disturbances and vision changes. Insomnia is not a typical manifestation of digoxin toxicity.
Full Explanation
Choice A rationale:
Hearing loss is not a typical sign of digoxin toxicity. Digoxin toxicity primarily affects the visual system, leading to disturbances such as blurred or yellow-tinted vision. It can also cause various cardiac symptoms due to its effects on heart rhythm and contractility. Hearing loss is not a recognized symptom of digoxin toxicity.
Choice B rationale:
Tachycardia (fast heart rate) can be a sign of digoxin toxicity. Digoxin can cause arrhythmias and alter heart rate, which may lead to tachycardia. While this is a possible symptom, it is not as specific as other manifestations, such as visual disturbances.
Choice C rationale:
Blurred vision is a hallmark sign of digoxin toxicity. Digoxin can cause disturbances in color vision, such as seeing yellow or green halos around objects. Blurred vision is a significant indicator of digoxin toxicity and requires prompt medical attention.
Choice D rationale:
Insomnia is not a recognized symptom of digoxin toxicity. Digoxin toxicity primarily affects the cardiovascular and visual systems, leading to symptoms related to heart rhythm disturbances and vision changes. Insomnia is not a typical manifestation of digoxin toxicity.
A nurse is planning assignments for the upcoming shift.
Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)
A. Transfer a client to physical therapy.
Transferring a client to physical therapy is a task that can be safely delegated to an assistive personnel (AP) as long as the client does not have any specific medical restrictions or requires specialized assistance during the transfer. APs are trained to assist with activities of daily living, including transferring clients from one place to another. However, it is essential for the nurse to assess the client's condition and provide clear instructions to the AP to ensure a safe transfer.
B. Obtain a client's vital signs every 4 hr.
Obtaining a client's vital signs every 4 hours is a routine task that can be delegated to an assistive personnel. APs are trained to measure vital signs such as blood pressure, heart rate, respiratory rate, and temperature under the supervision of licensed healthcare providers. Regular monitoring of vital signs is crucial in assessing the client's overall health status and detecting any changes that might require immediate medical attention.
C. Instruct a client on the use of an incentive spirometer.
Instructing a client on the use of an incentive spirometer requires specialized knowledge and assessment of the client's respiratory status. This task should be performed by a licensed healthcare provider, such as a nurse or respiratory therapist, who can properly assess the client's lung function, demonstrate the correct technique, and ensure the client's safety during the process. Delegating this task to an AP could result in improper use of the spirometer, potentially leading to complications or ineffective therapy.
D. Insert an NG tube for a client who requires enteral feedings.
Inserting an NG tube for a client who requires enteral feedings is a complex medical procedure that should be performed by a licensed nurse or healthcare provider with appropriate training and expertise. This procedure carries risks, including the risk of aspiration if not done correctly. Delegating this task to an AP is outside their scope of practice and could jeopardize the client's safety.
E. Record a client's intake after each meal.
Recording a client's intake after each meal is a task that can be delegated to an assistive personnel. APs can document the amount and type of food and fluids consumed by the client. Monitoring the client's intake is important, especially if the client has specific dietary restrictions, allergies, or medical conditions that require close monitoring of their food and fluid intake.
Full Explanation
Choice A rationale:
Transferring a client to physical therapy is a task that can be safely delegated to an assistive personnel (AP) as long as the client does not have any specific medical restrictions or requires specialized assistance during the transfer. APs are trained to assist with activities of daily living, including transferring clients from one place to another. However, it is essential for the nurse to assess the client's condition and provide clear instructions to the AP to ensure a safe transfer.
Choice B rationale:
Obtaining a client's vital signs every 4 hours is a routine task that can be delegated to an assistive personnel. APs are trained to measure vital signs such as blood pressure, heart rate, respiratory rate, and temperature under the supervision of licensed healthcare providers. Regular monitoring of vital signs is crucial in assessing the client's overall health status and detecting any changes that might require immediate medical attention.
Choice E rationale:
Recording a client's intake after each meal is a task that can be delegated to an assistive personnel. APs can document the amount and type of food and fluids consumed by the client. Monitoring the client's intake is important, especially if the client has specific dietary restrictions, allergies, or medical conditions that require close monitoring of their food and fluid intake.
Choice C rationale:
Instructing a client on the use of an incentive spirometer requires specialized knowledge and assessment of the client's respiratory status. This task should be performed by a licensed healthcare provider, such as a nurse or respiratory therapist, who can properly assess the client's lung function, demonstrate the correct technique, and ensure the client's safety during the process. Delegating this task to an AP could result in improper use of the spirometer, potentially leading to complications or ineffective therapy.
Choice D rationale:
Inserting an NG tube for a client who requires enteral feedings is a complex medical procedure that should be performed by a licensed nurse or healthcare provider with appropriate training and expertise. This procedure carries risks, including the risk of aspiration if not done correctly. Delegating this task to an AP is outside their scope of practice and could jeopardize the client's safety.
A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress.
Which of the following instructions should the nurse give the client about using progressive relaxation?
A. "Think about a positive outcome to a stressful situation.”
Thinking about a positive outcome to a stressful situation is a cognitive-behavioral technique that can help shift the client's focus from negative thoughts to positive ones. While this technique can be beneficial, it does not specifically pertain to progressive relaxation as described in choice B.
B. "Tighten a muscle group, then release the tension and move to the next one.”
Teaching the client to tighten a muscle group, release the tension, and then move to the next one is a technique used in progressive muscle relaxation (PMR) PMR is a stress management technique that involves tensing and relaxing different muscle groups to reduce muscle tension and promote relaxation. This method helps individuals become more aware of the sensations associated with muscle tension and relaxation, making it an effective strategy for managing anxiety and stress.
C. "Picture taking the stress you feel and pushing it down and out of your feet.”
Picturing taking the stress and pushing it out of the feet is a visualization technique, which can be helpful for some individuals in managing stress. However, it is not a component of progressive relaxation as described in choice B.
D. "Focus on a pleasant memory and express your emotions in writing.”
Focusing on a pleasant memory and expressing emotions in writing is a form of journaling or expressive writing, which can be a therapeutic technique for managing emotions and stress. While it can be a helpful strategy, it is not the same as progressive relaxation involving muscle tension and release.
Full Explanation
Choice B rationale:
Teaching the client to tighten a muscle group, release the tension, and then move to the next one is a technique used in progressive muscle relaxation (PMR) PMR is a stress management technique that involves tensing and relaxing different muscle groups to reduce muscle tension and promote relaxation. This method helps individuals become more aware of the sensations associated with muscle tension and relaxation, making it an effective strategy for managing anxiety and stress.
Choice A rationale:
Thinking about a positive outcome to a stressful situation is a cognitive-behavioral technique that can help shift the client's focus from negative thoughts to positive ones. While this technique can be beneficial, it does not specifically pertain to progressive relaxation as described in choice B.
Choice C rationale:
Picturing taking the stress and pushing it out of the feet is a visualization technique, which can be helpful for some individuals in managing stress. However, it is not a component of progressive relaxation as described in choice B.
Choice D rationale:
Focusing on a pleasant memory and expressing emotions in writing is a form of journaling or expressive writing, which can be a therapeutic technique for managing emotions and stress. While it can be a helpful strategy, it is not the same as progressive relaxation involving muscle tension and release.