Nokea
A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?
- A. Lemonade.
- B. Prune juice.
- C. Milk.
- D. Orange juice.
Correct Answer: B
Rationale: promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon
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A 19-year-old college student has a Mantoux test performed at the college health clinic. The result is positive. The clinic nurse should
- A. refer the student to an appropriate center for further testing.
- B. restrict the student's activity until his parents can be notified.
- C. notify the local Public Health Department.
- D. place the student in an isolation room in the college infirmary.
Correct Answer: A
Rationale: will perform chest x-ray
The nursing care plan for a five-year-old with a closed head injury should contain which of the following?
- A. Encourage child to sleep and decrease stimuli in the room.
- B. Assess orientation to person, place, and time every hour.
- C. Notify the physician regarding a negative Babinski reflex.
- D. Increase fluid intake to maintain adequate urinary output.
Correct Answer: B
Rationale: early signs of increased intracranial pressure are alterations in orientation
The nurse is caring for a client with a history of type 2 diabetes who is receiving glipizide (Glucotrol) 5 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Sweating and shakiness.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a serious glipizide side effect. Options A, C, and D are less urgent.
The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if performed by the nurse, is BEST?
- A. Change the IV tubing each time a new IV solution is hung.
- B. Cleanse the IV site with an alcohol swab using long strokes.
- C. Limit manipulation of the cannula at the IV insertion site.
- D. Adjust the drop rate to keep the total volume of IV fluids on schedule.
Correct Answer: C
Rationale: will prevent dislodgment of needle
An 8-year-old boy is brought to the physician’s office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial rash on the trunk of his body. Which of the following assessments would be MOST important for the nurse to perform?
- A. Grasp the child’s hands and ask him to squeeze the nurse’s hands.
- B. Stroke the plantar surface of the child’s foot with a reflex hammer.
- C. Gently flex the child’s head and neck onto the chest.
- D. Have the child stand with his eyes closed, his arms at his sides, and his feet and knees close together.
Correct Answer: C
Rationale: Fever, headache, nausea, and petechial rash suggest meningitis; flexing the neck (Brudzinski’s sign) assesses meningeal irritation, a priority. Options A, B, and D are less relevant: hand squeeze is nonspecific, Babinski’s sign is not indicated, and Romberg’s sign assesses balance.