Nokea
16. Which statement accurately describes the common use of feverfew?
- A. Frequently used for insomnia and anxiety
- B. Most commonly used for prevention of migraine headaches
- C. Frequently used to prevent and treat upper respiratory infections
- D. Often used by perimenopausal women to relieve menopausal symptoms
Correct Answer: B
Rationale: Feverfew is most commonly used for the prevention of migraine headaches, making option B the correct answer.
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To attain the goal of ambulation for the patient who is hemiplegic, the initial care plan needs to be structured to first attain
- A. acceptance of his altered body image
- B. balance training
- C. adequate energy level
- D. ability to transfer from bed to chair
Correct Answer: D
Rationale: The ability to transfer from bed to chair is a critical first step in preparing a hemiplegic patient for ambulation. This foundational skill builds confidence and strength before progressing to balance training or walking.
Which nursing diagnosis is appropriate for a client on a fluid restriction?
- A. Excess fluid volume related to intake that exceeds fluid loss
- B. Altered comfort: dry mouth and thirst related to restricted oral fluid
- C. Risk for impaired skin integrity related to compromised circulation secondary to edema
- D. Fluid volume deficit secondary to dehydration
Correct Answer: B
Rationale: A fluid restriction often leads to dry mouth and thirst, making 'Altered comfort' the most relevant nursing diagnosis.
A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?
- A. Since many of your family members are carriers, your children will also be carriers of the gene.
- B. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder.
- C. Since you have a family history of cystic fibrosis, I would encourage you & your partner to be tested.
- D. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.
Correct Answer: C
Rationale: Rationale:
C is correct because it encourages genetic testing for both the client and their partner to assess the risk of passing on the cystic fibrosis gene. This approach provides the necessary information for informed decision-making regarding family planning. A is incorrect because being a carrier does not guarantee that the children will also be carriers. B is incorrect as it inaccurately states that if the client is a carrier, their children will have the disorder. D is incorrect because it oversimplifies the etiology of cystic fibrosis and suggests dietary adjustments as a solution, which is not effective in managing the genetic condition.
A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?
- A. Administer an IV fluid bolus.
- B. Check the surgical site for bleeding.
- C. Place the client in a Trendelenburg position.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Check the surgical site for bleeding. This is the first action the nurse should take as a sudden drop in blood pressure postoperatively could indicate internal bleeding, a common complication after abdominal surgery. By assessing the surgical site for bleeding, the nurse can identify and address the source of the hypotension promptly. Administering IV fluids (choice A) may be necessary but should come after determining the cause. Placing the client in Trendelenburg position (choice C) is not recommended as it can worsen venous return and increase intracranial pressure. Notifying the healthcare provider (choice D) should be done after the nurse has assessed the situation and taken immediate action.
Total parenteral nutrition(TPN), is one of the home therapies being used for Chelsea Mann, 35, with acute ulcerative colitis causing massive diarrhea. She and her family will need instruction about:
- A. caring for the central catheter.
- B. how to mix the TPN solution.
- C. fixing malfunctions occuring in the IV pump.
- D. teaching the neighbors how to care for her.
Correct Answer: A
Rationale: Prevention of infection, and potential septicemia, is of prime importance for someone with a central catheter. Mixing TPN is a very specialized procedure, and should be done under laminar airflow by a pharmacist. IV pumps are machines that do malfunction, but the safest thing to do would be to get the manufacturer to do the repair. Having neighbors be a support to Chelsea and her family may not be possible. More information would be necessary prior to choosing this as an option for a nursing diagnosis.