Nokea
A 32 year-old male with a complaint of dizziness has an order for Morphine via. IV. The nurse should do which of the following first?
- A. Check the patient's chest x-ray results.
- B. Retake vitals including blood pressure.
- C. Perform a neurological screen on the patient.
- D. Request the physician on-call assess the patient.
Correct Answer: B
Rationale: Dizziness can be a sign of hypotension, that may a contraindication with Morphine.
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A nurse suspects a patient is developing Bell's Palsy. The nurse wants to test the function of cranial nerve VII. Which of the following would be the most appropriate testing procedures?
- A. Test the taste sensation over the back of the tongue and activation of the facial muscles.
- B. Test the taste sensation over the front of the tongue and activation of the facial muscles.
- C. Test the sensation of the facial muscles and sensation of the back of the tongue.
- D. Test the sensation of the facial muscles and sensation of the front of the tongue.
Correct Answer: B
Rationale: The facial nerve (VII) is motor to the face and sensory to the anterior tongue.
Which of the following developmental milestones for a 6-month-old child should be screened by the nurse during a routine office visit?
- A. standing while holding something
- B. rolling over
- C. sitting up
- D. creeping
Correct Answer: B
Rationale: Rolling over occurs between 4 and 6 months of age. Sitting up occurs between 7 and 8 months, creeping between 9 and 10 months, and standing between 8 and 10 months.
What action should the nurse take?
- A. Reassure patient that pain is normal following surgery.
- B. Administer pm Nifedipine and assess client's response.
- C. Administer pm Meperidine HCL and assess client's response.
- D. Recheck BP and pulse rate every 20 minutes for the next hour.
Correct Answer: C
Rationale: A sinus tachycardia is a physiological response to pain. Treating the cause of the increased pulse rate requires pain medication.
A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?
- A. Immunizations may be started at any age.
- B. The recommended immunization schedule must be followed exactly.
- C. If a primary series of immunizations is interrupted, the series must be restarted.
- D. This child is at increased risk for reaction to the vaccines, when they are started.
Correct Answer: A
Rationale: While a recommended immunization schedule exists, immunizations may be started at any age. An interrupted series may be continued and need not be restarted. There is no increased risk for reaction to vaccines due to delay.
Which of the following substances need to be assessed when completing a family health assessment?
- A. coffee, tea, cola, and cocoa
- B. alcohol, tobacco, and illegal substances
- C. medicines prescribed by a physician
- D. all of the above
Correct Answer: D
Rationale: When assessing drug, alcohol, and tobacco practices among family members, a thorough investigation of prescribed, over-the-counter, and illegal substance-use practices should be made.