The nurse is talking with a client who is receiving phenytoin. Which of the following statements by the client would require immediate follow-up?

• I have begun to feel unsteady while walking.
• I wake up frequently during the night to urinate.
• There is a metallic taste in my mouth when I eat.
• There is mild swelling and tenderness in my gums.
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The nurse in the emergency department is caring for assigned clients. Which of the following clients should the nurse assess first?

• 1-year-old client with a ventriculoperitoneal shunt who is lethargic and has bradycardia
• 3-year-old client with a history of meningocele who has unilateral ear pain and urinary incontinence
• 6-year-old client with muscular dystrophy who has flu-like symptoms and a temperature of 100.4 F (38 C)
• 8-year-old client with a history of cerebral palsy who has a foot injury and spastic clonus
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The nurse in the same-day surgery unit admits a client who will receive general anesthesia. The client has never had surgery before. Which question is most critical for the nurse to ask the client during the preoperative assessment and health history?

• Has any family member ever had a bad reaction to general anesthesia?
• Have you ever experienced low back pain?
• Have you ever had an anaphylactic reaction to a bee sting?
• Have you ever received opioid pain medications?
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The clinic nurse performs assessments on four infants. The nurse should alert the health care provider to see which client first?

• 3-month-old whose posterior occiput appears flattened
• 4-month-old who has sclera visible above the iris (sunset eyes)
• 6-month-old who has vomited twice and has had 8 wet diapers in the last 24 hours
• 9-month-old whose toes fan out and big toe dorsiflexes when plantar surface is stroked
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The health care provider prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose?

• To lower the blood alcohol level
• To prevent gross tremors
• To prevent Wernicke encephalopathy
• To treat seizures related to acute alcohol withdrawal
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A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which supplement might help synchronize the body to environmental time?

• Evening primrose
• Ginseng
• Melatonin
• St. John wort
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The nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII). Which direction should the nurse give the client to test this cranial nerve?

• Close your eyes and identify this smell.
• Follow my finger with your eyes without moving your head.
• Look straight ahead and let me know when you can see my finger.
• Raise your eyebrows, smile, and frown.
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The nurse has been made aware of laboratory test results for assigned clients. Which of the following test results would require immediate follow-up?

• phenytoin level of 8 mcg/mL for a client who is receiving enteral feedings
• digoxin level of 1.3 ng/ml for a client who has a heart rate of 62/min
• lithium level of 0.8 mEq/L for a client who is reporting a decreased appetite
• international normalized ratio (INR) of 3 for a client who has a prosthetic aortic valve
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The nurse is preparing to administer sumatriptan to a client with a migraine headache. Which of the following findings would require follow-up prior to administering the medication?

• BMI of 34 kg/m2 recorded during today's examination
• past medical history of uncontrolled hypertension
• takes alprazolam as prescribed for anxiety
• BUN of 12 mg/dL
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The nurse is caring for a client who is experiencing hypotension and respiratory depression after receiving IV midazolam. Which of the following medications should the nurse anticipate administering to the client?

• benztropine
• acetylcysteine
• flumazenil
• phentolamine
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