Milestone Exam 1 EXAM QUESTIONS WITH
COMPLETE SOLUTION GUIDE (A+ GRADED 100%
VERIFIED) LATEST VERSION 2025!!
Two hours after taking the first dose of penicillin, a client arrives at the
emergency department complaining of feeling ill, exhibiting hives, having
difficulty breathing, and experiencing hypotension. The nurse will develop an
immediate plan of care based on which finding?
A.Severe acute anaphylactic response
B.Side reaction that should resolve
C.Idiosyncratic reaction
D.Cumulative drug response
A - (answers)Rationale: Anaphylaxis related to penicillin can cause a life-
threatening allergic response characterized by bronchospasm, laryngeal edema,
and a precipitous drop in blood pressure. This client's ingestion of penicillin and
presenting clinical picture indicate the client is having an acute reaction with
respiratory difficulty. Options B, C, and D are other physiologic responses to
medications, but immediate action is required for a potential loss of airway,
breathing, and circulation.
Which response best supports the observations that the nurse identifies in a
client who is experiencing a placebo effect?
A.Beneficial response or cure for disease
B.Behavioral or psychotropic responses
C.Malingering or drug-seeking behaviors
D.Psychological response to inert medication
, D - (answers)Rationale:The placebo effect is a response in the client that is caused
by the psychological impact of taking an inert drug that has no biochemical
properties. A placebo effect can be therapeutic, negative, or ineffective but
provides no cure or benefit to the client's progress. The placebo effect may evoke
behavioral changes but does not affect neurochemical psychotropic changes.
Malingering and drug seeking are behaviors that a client exhibits to obtain
treatment for nonexistent disorders or obtain prescription medications.
A mother brings her 18-month-old child to the community health center because
the child has had "bad diarrhea" for the last 3 days. She states, "I bought some of
this liquid at the pharmacy and gave my child a half-ounce." The nurse sees that
the bottle contains loperamide. What is the next nursing action?
A.Tell the mother never to give this drug to her toddler.
B.Ask if any other siblings have experienced diarrhea.
C.Take the child's oral and tympanic temperatures.
D.Ask the mother when the child last voided.
D - (answers)Rationale: Determining when the child last voided is most important
because urine output is decreased with dehydration and an 18-month-old with a
3-day history of diarrhea could be severely dehydrated. Although the
manufacturer states that loperamide should not be given to a child younger than
2 years except under the direction of a health care provider, option A is not the
best answer for this question. In addition, loperamide causes an anticholinergic
effect of urinary retention. Data obtained in options B and C are not as high a
priority as option D in this situation.
A client receives an antihypertensive agent daily. Which action is most important
for the nurse to implement prior to administering the medication?
A.Verify the expiration date.
COMPLETE SOLUTION GUIDE (A+ GRADED 100%
VERIFIED) LATEST VERSION 2025!!
Two hours after taking the first dose of penicillin, a client arrives at the
emergency department complaining of feeling ill, exhibiting hives, having
difficulty breathing, and experiencing hypotension. The nurse will develop an
immediate plan of care based on which finding?
A.Severe acute anaphylactic response
B.Side reaction that should resolve
C.Idiosyncratic reaction
D.Cumulative drug response
A - (answers)Rationale: Anaphylaxis related to penicillin can cause a life-
threatening allergic response characterized by bronchospasm, laryngeal edema,
and a precipitous drop in blood pressure. This client's ingestion of penicillin and
presenting clinical picture indicate the client is having an acute reaction with
respiratory difficulty. Options B, C, and D are other physiologic responses to
medications, but immediate action is required for a potential loss of airway,
breathing, and circulation.
Which response best supports the observations that the nurse identifies in a
client who is experiencing a placebo effect?
A.Beneficial response or cure for disease
B.Behavioral or psychotropic responses
C.Malingering or drug-seeking behaviors
D.Psychological response to inert medication
, D - (answers)Rationale:The placebo effect is a response in the client that is caused
by the psychological impact of taking an inert drug that has no biochemical
properties. A placebo effect can be therapeutic, negative, or ineffective but
provides no cure or benefit to the client's progress. The placebo effect may evoke
behavioral changes but does not affect neurochemical psychotropic changes.
Malingering and drug seeking are behaviors that a client exhibits to obtain
treatment for nonexistent disorders or obtain prescription medications.
A mother brings her 18-month-old child to the community health center because
the child has had "bad diarrhea" for the last 3 days. She states, "I bought some of
this liquid at the pharmacy and gave my child a half-ounce." The nurse sees that
the bottle contains loperamide. What is the next nursing action?
A.Tell the mother never to give this drug to her toddler.
B.Ask if any other siblings have experienced diarrhea.
C.Take the child's oral and tympanic temperatures.
D.Ask the mother when the child last voided.
D - (answers)Rationale: Determining when the child last voided is most important
because urine output is decreased with dehydration and an 18-month-old with a
3-day history of diarrhea could be severely dehydrated. Although the
manufacturer states that loperamide should not be given to a child younger than
2 years except under the direction of a health care provider, option A is not the
best answer for this question. In addition, loperamide causes an anticholinergic
effect of urinary retention. Data obtained in options B and C are not as high a
priority as option D in this situation.
A client receives an antihypertensive agent daily. Which action is most important
for the nurse to implement prior to administering the medication?
A.Verify the expiration date.
