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NEW QUESTION 41
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:

• A. Stephens-Johnson syndrome
• B. Granulocytosis and nephrosis
• C. Folate deficiency
• D. Leukopenic aplastic anemia

Answer: A

Explanation:
Explanation/Reference:
Explanation:
(A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). (D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).

NEW QUESTION 42
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?

• A. "I'll be sure to walk at least 2-3 blocks every day."
• B. "I'll be sure to rise slowly and sit for a few minutes after lying down."
• C. "I'll be sure to restrict my fluid intake to four or five glasses a day."
• D. "I'll be sure not to take any more aspirin while I am on this drug."

Answer: B

Explanation:
Section: Questions Set B
Explanation:
(A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to ensure that their fluid intake is at least 2000-3000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide.

NEW QUESTION 43
After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?

• A. One centimeter below the ischial spines
• B. Located in the pelvic outlet
• C. One centimeter above the ischial spines
• D. Has not entered the pelvic inlet yet

Answer: C

Explanation:
Explanation
(A) The ischial spines are located on both sides of the midpelvis. These spines mark the diameter of the narrowest part of the pelvis that the fetus will encounter. They are not sharp protrusions that will harm the fetus. Station refers to the relationship between the ischial spines in the pelvis and the fetus. The ischial spines are designated at 0 station. If the presenting part of the fetus is located above the ischial spines, a negative number is assigned, noting the number of centimeters above the ischial spines. Therefore, 1 centimeter below the ischial spines is designated as +1 station. (B) See explanation in A. One centimeter above the ischial spines is designated as +1 station. (C) The pelvic inlet is the first part of the pelvis that the fetus enters in routine delivery. The midpelvis is the second part of the pelvis to be entered by the fetus. The ischial spines are located on both sides of the midpelvis. (D) The pelvic outlet is the last part of the pelvis that the fetus will enter. When the fetus reaches this part of the pelvis, birth is near.

NEW QUESTION 44
A young boy tells the nurse, "I don't like my Dad to kiss or hug my Mom. I love my Mom and want to marry her." The nurse recognizes this stage of growth and development as:

• A. Electra complex
• B. Oedipus complex
• C. Ego
• D. Superego

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A) The Electra complex is the erotic attachment of the female child to the father. (B) The Oedipus complex is characterized by jealousy toward the parent of the same sex and erotic attachment to the parent of the opposite sex. (C) The superego as described by Freud is the part of personality that is associated with internalized parental and societal control. (D) The ego as described by Freud is the part of personality that is associated with reality assessment.

NEW QUESTION 45
When planning care for the passive-aggressive client, the nurse includes the following goal:

• A. Allow the client to use humor, because this may be the only way this client can express self.
• B. Allow the client to give excuses if he forgets to give staff information.
• C. Allow the client to express anger by using "I" messages, such as "I was angry when . . .," etc.
• D. Allow the client to have time away from therapeutic responsibilities.

Answer: C

Explanation:
Explanation/Reference:
Explanation:
(A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of "I" messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior.
(C) Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.

NEW QUESTION 46
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