Nokea
The nurse is working in a high risk antepartum clinic. A 40 year-old woman in the first trimester gives a thorough health history. Which information should receive priority attention by the nurse?
- A. Her father and brother are insulin-dependent diabetics
- B. She has taken 800 mcg of folic acid daily for the past year
- C. Her husband was treated for tuberculosis as a child
- D. She reports recent use of over-the-counter sinus remedies
Correct Answer: D
Rationale: Over-the-counter drugs are a possible danger in early pregnancy. A report by the client that she has taken medications should be followed up immediately.
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The nurse is talking with a client. The client abruptly says to the nurse, 'The moon is full. Astronauts walk on the moon. Walking is a good health habit.' The client's remarks most likely indicate
- A. Neologisms
- B. Flight of ideas
- C. Loose associations
- D. Word salad
Correct Answer: C
Rationale: Loose associations. The client's statements are loosely connected by related words, indicating disorganized thought.
A client with ulcerative colitis is taking Azulfidine (Sulfasalazine). Which of the following instructions should be included in the nurse's teaching?
- A. The client should be instructed to take a laxative to prevent constipation.
- B. The client should be instructed to take the medication with meals.
- C. The client should be instructed to take the medication even when he is feeling well.
- D. The client should be instructed to take the medication as prescribed because it will stop the loss of blood in the stools.
Correct Answer: C
Rationale: Azulfidine is a maintenance medication for ulcerative colitis, and clients should continue taking it even during remission to prevent flare-ups.
What is most likely occurring when persistent bubbling exist in the water seal chamber of a chest drainage device?
- A. There is an excessive amount of wall suction.
- B. The amount of suction needs to be increased.
- C. The patient's chest tube is probably kinked.
- D. There is an air leak in the chest tube or pleural cavity.
Correct Answer: D
Rationale: Persistent bubbling indicates an air leak, either in the system or from the lung.
Considering the group's developmental needs, the type of learning activity planned by the nurse would be:
- A. Include the parents in the teaching sessions.
- B. Teach about physiology of puberty.
- C. Ensure participants make independent decisions about their treatment.
- D. Plan activities that will encourage peer-support.
Correct Answer: D
Rationale: Peer-support activities align with adolescents' developmental need for social connection and shared experiences.
The nurse is caring for a person admitted with myasthenia gravis. What should be included in the nursing care plan for this person?
- A. Have the client bathe late in the day.
- B. Check swallowing reflexes before feeding.
- C. Have the client void every hour.
- D. Observe for signs of neuropathy.
Correct Answer: B
Rationale: Myasthenia gravis causes muscle weakness, increasing aspiration risk; checking swallowing reflexes ensures safe feeding. Other actions are irrelevant.