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A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?
- A. Black, sticky stools
- B. Greasy, foul-smelling stools
- C. Stools mixed with blood and mucus
- D. Thin, 'ribbon-like' stools
Correct Answer: C
Rationale: Intussusception causes intestinal obstruction, often leading to 'currant jelly' stools (blood and mucus). Black, sticky stools suggest upper GI bleeding. Greasy stools indicate malabsorption. Ribbon-like stools suggest rectal narrowing.
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The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. The need to avoid which of these should be emphasized to the client?
- A. Large indoor gatherings
- B. Exposure to sunlight
- C. Active physical exercise
- D. Foods rich in vitamin K
Correct Answer: D
Rationale: Foods rich in vitamin K. Vitamin K acts as an antidote to the pharmacologic action of Coumadin therapy, decreasing Coumadin's effectiveness. Foods high in vitamin K include dark greens, tomatoes, bananas, cheese, and fish.
The nurse is caring for an adult being admitted with a head injury. The nurse plans to place the client in which position?
- A. Prone
- B. Supine
- C. Semi-reclining
- D. Upright
Correct Answer: C
Rationale: Semi-reclining (30-45 degrees) reduces intracranial pressure in head injury by promoting venous drainage, unlike prone, supine, or upright positions.
A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse anticipate in this client's care plan?
- A. Encourage client to drink cold beverages
- B. Encourage client to eat a high-fiber diet
- C. Encourage client to perform facial massage
- D. Encourage client to report any fever or sore throat
Correct Answer: D
Rationale: Carbamazepine can cause agranulocytosis or infections; fever or sore throat must be reported. Cold beverages may trigger trigeminal neuralgia pain. High-fiber diets and facial massage are unrelated to management.
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should
- A. Offer small meals of high calorie soft food
- B. Assist the client to sit in a chair for meals
- C. Provide additional servings of fruits and raw vegetables
- D. Encourage the client to eat fish, liver and chicken
Correct Answer: A
Rationale: Offer small meals of high calorie soft food. High-calorie soft foods minimize chewing, providing nourishment with less pain.
The nurse is observing a nursing assistant transfer a client from bed to chair. Which observation needs correction? Select all that apply.
- A. The nursing assistant lowers the bed before starting the procedure.
- B. The nursing assistant sits the client on the side of the bed before assisting the client to move.
- C. The nursing assistant stands with feet close together and knees and back straight when helping the client to move.
- D. The nursing assistant asks the client to grab the arm of the nursing assistant during the transfer.
- E. The nursing assistant lifts the client up by tugging on the client's arms.
- F. The nursing assistant assists the client to stand and pivot to get into the chair.
Correct Answer: C,D,E
Rationale: The nursing assistant should stand with feet apart and knees bent to prevent injury, not grab the client's arm, and avoid tugging on the client's arms. Lowering the bed, sitting the client up, and assisting to pivot are correct.