The nurse has administered warfarin 2.5 mg orally daily for three days to a client who has deep vein thrombosis. The client's International Normalized Ratio (INR) today is 5.0. The nurse notifies the healthcare provider because today's dose of the medication should be:

Switched to heparin.

Given as prescribed.

Increased.

Held.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Switching to heparin is not the standard response for a high INR. Heparin may be used in conjunction with warfarin when starting anticoagulation therapy, but it is not typically used as a substitute in response to an elevated INR.

Choice B Reason:
Giving the dose as prescribed would not be appropriate when the INR is significantly above the therapeutic range. Continuing the same dose could increase the risk of bleeding complications.

Choice C Reason:
Increasing the dose would be contraindicated as the INR is already too high. Increasing the warfarin dose would further elevate the INR and increase the risk of bleeding.

Choice D Reason:
Holding the dose is the correct action when the INR is significantly above the therapeutic range, which is generally between 2.0 to 3.0 for most indications. The healthcare provider should be notified, and the warfarin dose should be held until the INR returns to the therapeutic range. Vitamin K may also be administered to help lower the INR more quickly if necessary.

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Correct Answer is D

Explanation

Choice a reason:
An increase in urine output can be a sign of improved kidney function or the effect of medications, but it is not a direct indicator of reduced cardiac workload. Atenolol, a beta-blocker, primarily reduces the heart rate and myocardial oxygen demand, not urine output.

Choice b reason:
Less dyspnea with activity suggests improved cardiovascular efficiency, but it is not a specific measure of cardiac workload. Dyspnea can be influenced by respiratory conditions and is not solely determined by cardiac function.

Choice c reason:
A blood pressure of 120/80 mmHg is considered optimal for most adults and indicates good control of hypertension. However, it does not specifically reflect the cardiac workload, which is more directly affected by heart rate and myocardial oxygen demand.

Choice d reason:
A heart rate of 65 per minute is a clear indicator that atenolol is effective in reducing cardiac workload. Atenolol decreases the heart rate, which in turn reduces myocardial oxygen demand and the overall workload on the heart. This is particularly important for patients with unstable angina, where reducing the heart's workload can prevent angina attacks and potential myocardial infarction.

A. Autism Spectrum Disorder B. Stereotypic Movement Disorder C. Attention Deficit Hyperactivity Disorder D. Intellectual Disability Disorder

Correct Answer is A

Explanation

Choice A Reason:
Autism Spectrum Disorder (ASD) is characterized by challenges with social skills, repetitive behaviors, and communication difficulties. Jaw clenching and rocking are forms of self-stimulatory behavior (stimming) often observed in individuals with ASD¹³¹⁴. These behaviors can serve as a coping mechanism to manage sensory overload or express emotions.

Choice B Reason:
Stereotypic Movement Disorder involves repetitive, seemingly purposeless movements. While jaw clenching and rocking could be symptoms, they are more commonly associated with ASD. Stereotypic Movement Disorder is typically diagnosed when these behaviors interfere significantly with normal activities or result in self-harm, which is not mentioned in the child's description.

Choice C Reason:
Attention Deficit Hyperactivity Disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. The behaviors described, jaw clenching and rocking, are not typical indicators of ADHD, which more commonly includes symptoms like difficulty staying focused, hyperactivity, and impulsive actions.

Choice D Reason:
Intellectual Disability Disorder is characterized by limitations in intellectual functioning and adaptive behavior, which covers a range of everyday social and practical skills. The behaviors of jaw clenching and rocking do not directly indicate Intellectual Disability Disorder. This condition is usually identified by deficits in intellectual and adaptive functioning, not by specific behaviors like those described.

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The nurse has administered warfarin 2.5 mg orally daily for three days to a client who has deep vein thrombosis. The client's International Normalized Ratio (INR) today is 5.0. The nurse notifies the healthcare provider because today's dose of the medication should be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies that the goal of decreasing the cardiac workload for a client receiving atenolol 25 mg PO BID for unstable angina is met when the client has:

Correct Answer is D

Explanation

A 7-year-old child without any other diagnosed problems engages in jaw clenching and rocking behaviors. Which condition should the nurse anticipate?

Correct Answer is A

Explanation

Two months after beginning drug therapy with alprazolam, a client states, "I feel much better, but I can't believe how dizzy and light-headed I get, and sometimes my mouth feels dry." Which would be the priority response by the nurse?

Which statement, made by the client diagnosed with unstable angina, reflects an understanding of the nurse's discharge teaching?

A client was admitted to the emergency department with slurred speech and impaired motor coordination. The blood alcohol level is over 300 mg/dL. The physician orders thiamine for the client. The nurse understands that the physician ordered thiamine to:

A common sign of hypoglycemia in a client diagnosed with diabetes is:

The nurse is providing discharge teaching to a client after a total hip replacement. The teaching should include instructions to:

A client diagnosed with schizophrenia functions well during hospitalization but decompensates after discharge. What does the therapeutic milieu provide that may be missing in the home environment?

Which data is cause for immediate intervention for a client after a right shoulder replacement?

A client is receiving gentamicin and vancomycin IV for urosepsis. Which diagnostic study result should the nurse report to the primary care practitioner?