Nokea
\What should the nurse teach an older client with TIA?
- A. Not to worry about the symptoms that are part of the normal aging process
- B. To admit oneself to a rehabilitation center or a nursing home for rehabilitation
- C. To comply with the medication regimen
- D. To observe any changes in the nails and skin
Correct Answer: C
Rationale: The nurse should teach an older client with a transient ischemic attack (TIA) to comply with the medication regimen. TIA is a warning sign of a potential stroke, and medication compliance is crucial in reducing the risk of a future stroke. Medications prescribed after a TIA may include blood thinners, antiplatelet agents, antihypertensives, and cholesterol-lowering drugs. It is essential for the client to take these medications as directed by their healthcare provider to prevent further cardiovascular events. Compliance with the medication regimen plays a significant role in managing the risk factors associated with stroke and promoting long-term health and well-being.
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A 45-year-old patient has a long- standing history of allergies to pollen. Which of the following actions indicates that the patient does not understand how to control this disease?
- A. Staying indoors on dry, windy days.
- B. Refusing to walk outside in the spring.
- C. Driving in the care with the windows open.
- D. Working in the garden on sunny days.
Correct Answer: C
Rationale: Driving in the car with the windows open is not a recommended action for someone with allergies to pollen. Keeping the windows closed while driving can help minimize exposure to pollen particles in the air. By driving with the windows open, the individual is increasing their exposure to pollen and not effectively controlling their allergy symptoms. Staying indoors on dry, windy days (Choice A), refusing to walk outside in the spring (Choice B), and working in the garden on sunny days (Choice D) are all actions that demonstrate understanding of how to control allergies to pollen by avoiding potential triggers.
You are evaluating a 6-year-old male child with Langerhans cell histiocytosis (LCH); the parents state that the most common site of bone involvement is
- A. skull
- B. vertebra
- C. mandible
- D. pelvis
Correct Answer: A
Rationale: Skull is the most common site of bone involvement in LCH.
One nursing diagnosis for JRA is impaired physical mobility. Select all nursing interventions that apply.
- A. Give pain medication prior to ambulation.
- B. Assist with range-of-motion activities.
- C. Encourage the child to eat a high-fat diet.
- D. Provide oxygen as necessary.
Correct Answer: A
Rationale: Giving pain medication prior to ambulation can help alleviate discomfort and improve the child's ability to perform physical activities, thus promoting mobility.
A nurse is assessing a 5 year old with a history of heart failure. Which finding indicates that the child has adequate cardiac output?
- A. Urine output of 30 mL/h
- B. Heart rate of 120 beats/min
- C. Cap refill time of 10 to 15 sec
- D. Bilateral crackles heard on auscultation.
Correct Answer: A
Rationale: Adequate cardiac output is a measure of how well the heart is able to pump blood effectively to meet the body's metabolic demands. An adequate cardiac output ensures sufficient oxygen and nutrients are delivered to the tissues and organs. One of the most reliable indicators of adequate cardiac output is urine output. A urine output of at least 1 mL/kg/hour, which translates to around 30 mL/hour in a 5-year-old child, indicates adequate perfusion and renal function. In heart failure, decreased cardiac output may lead to decreased renal perfusion, resulting in a decreased urine output, so a stable or increased urine output suggests adequate cardiac output.
A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
- A. to increase bladder atony
- B. to maintain patency of the foley
- C. to remove blood clots from the bladder catheter
- D. to lower the specific gravity of the urine
Correct Answer: A
Rationale: Cystoclisis refers to the continuous irrigation of the bladder with a sterile solution to maintain bladder atony. This procedure is commonly done to provide continuous bladder drainage, prevent clot formation, and promote urinary flow. By continuously irrigating the bladder, it helps to keep the bladder decompressed and prevent the overdistension of the bladder muscles, especially in patients with impaired bladder emptying or bladder dysfunction. Therefore, the purpose of cystoclisis is to increase bladder atony rather than the other options listed.