Nokea
A 1-year-old boy is hospitalized for a fractured femur. There is a PRN order for pain medication. What is the best way to assess the child for pain?
- A. Ask the parent who is present if the child appears to be in pain.
- B. Observe the child's behavior carefully.
- C. Ask the child where it hurts and how badly it hurts.
- D. Have the child look at pictures of faces and select the one that best describes how he feels right now.
Correct Answer: B
Rationale: A 1-year-old cannot verbalize pain; observing behavior (e.g., crying, guarding) is the most reliable pain assessment method.
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An adult is prescribed lovastatin (Mevacor). The nurse should teach the client that while he is taking lovastatin (Mevacor), he must avoid:
- A. eating apples.
- B. drinking grapefruit juice.
- C. using aspirin.
- D. using ibuprofen.
Correct Answer: B
Rationale: Grapefruit juice inhibits CYP3A4, increasing lovastatin levels and risking toxicity, such as myopathy. Apples, aspirin, and ibuprofen do not have significant interactions with lovastatin.
When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by
- A. Reduced oxygen capacity of cells due to lack of iron
- B. An imbalance between red cell destruction and production
- C. Depression of red and white cells and platelets
- D. Inability of sickle shaped cells to regenerate
Correct Answer: B
Rationale: An imbalance between red cell destruction and production. Anemia results when the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow (red cell life span shortened from 120 days to 12-20 days).
A client diagnosed with trichomonal vaginal infection (trichomoniasis) is prescribed metronidazole. Which directions are essential for the nurse to reinforce? Select all that apply.
- A. Avoid alcohol while taking this medication
- B. Perform vaginal douche for 7-10 days
- C. Use birth control pills to prevent infection recurrence
- D. Your partner(s) must be treated simultaneously
- E. Your urine can change to a deep red-brown color
Correct Answer: A,D,E
Rationale: Metronidazole treatment for trichomoniasis requires specific instructions. Avoiding alcohol (A) prevents a disulfiram-like reaction. Partner treatment (D) is essential to prevent reinfection, as trichomoniasis is sexually transmitted. Urine discoloration (E) is a possible side effect to anticipate. Douching (B) is not recommended, as it disrupts vaginal flora. Birth control pills (C) do not prevent recurrence of this infection.
An adult client is showing signs of developing hypovolemic shock. Which finding is most likely to be present?
- A. Elevated systolic and lowered diastolic blood pressure
- B. Decreased heart rate
- C. Decreased urine output
- D. Decreased respiratory rate
Correct Answer: C
Rationale: Hypovolemic shock reduces circulating volume, decreasing renal perfusion and causing oliguria (decreased urine output). Blood pressure typically narrows, heart rate increases, and respiratory rate rises.
An adult has started on continuous ambulatory peritoneal dialysis. Which nursing instruction is of highest priority?
- A. Explain the principles of osmosis and diffusion and how dialysis works
- B. Teach the client aseptic technique
- C. Plan to withhold all drugs during dialysis
- D. Encourage the client to eat a high-sodium, high-potassium diet
Correct Answer: B
Rationale: Aseptic technique is critical in peritoneal dialysis to prevent peritonitis, a serious complication. Understanding dialysis mechanics, withholding drugs, or diet are secondary.