Nokea
A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?
- A. Allow her to ambulate unassisted, to encourage positive self-esteem.
- B. Ask her to demonstrate her ability to ambulate.
- C. Explain that someone will assist her as long as she is in the rehabilitation facility.
- D. Ask another staff member to help ambulate the patient the first time.
Correct Answer: C
Rationale: The best response by the nurse is to explain that someone will assist the patient as long as she is in the rehabilitation facility. This is important for ensuring the safety of the patient, especially considering her condition with left-sided hemiparesis resulting from a subarachnoid hemorrhage. While encouraging independence is important in rehabilitation, it should not compromise the patient's safety. The nurse should prioritize the patient's well-being and provide necessary assistance to prevent any potential falls or injuries during ambulation.aising the risk of falling or getting injured.
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The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the nurse what will happen to their child's skin after the infection has subsided and healed. Which answer should the nurse give?
- A. There will be no scarring.
- B. There may be some pigmented spots.
- C. It is likely there will be some slightly depressed scars.
- D. There will be some atrophic white scars.
Correct Answer: A
Rationale: Impetigo contagiosa typically does not leave scarring once it has subsided and healed. This skin infection primarily affects the superficial layers of the skin and does not cause damage deep enough to result in scarring. While there may be some temporary pigmented spots or mild changes in skin color after the infection resolves, scarring is not a common outcome of impetigo contagiosa in most cases. Thus, the nurse should reassure the parents that their child's skin is not likely to have any scarring after the infection has healed.
A client with HIV has been prescribed anti viral medications. What instructions related to administration of medications should the nurse give such a client?
- A. Comply with the timing of antiviral medication around meals
- B. Avoid exposure to harsh sunlight for about 2hrs after taking the medication
- C. Have the medications with plenty of fruit juice
- D. Have an increased dose of the medications if the symptoms worsen
Correct Answer: A
Rationale: The nurse should instruct the client to comply with the timing of antiviral medication around meals. Taking some antiviral medications with food can help reduce gastrointestinal side effects. Certain medications may be more effective when taken with food, while others may need to be taken on an empty stomach. It is essential for the client to follow the specific instructions given by their healthcare provider to ensure the optimal effectiveness of the antiviral medications.
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self- examination. Which assessment finding would strongly suggest that this client's lump is cancerous?
- A. Eversion of the right nipple and mobile mass
- B. Mobile mass that is soft and easily
- C. Non-mobile mass with irregular edges delineated
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: The assessment finding that strongly suggests that the client's lump is cancerous is a non-mobile mass with irregular edges delineated. Generally, cancerous breast lumps tend to have irregular shapes/edges and lack mobility. This finding is concerning for malignancy because it indicates that the lump is fixed in place and possibly invading nearby tissues, which are characteristics often associated with cancerous tumors. It's essential for the client to undergo further diagnostic tests, such as a biopsy, to confirm the presence of cancer and establish a proper treatment plan.
Failure to thrive (FTT) is a descriptive term given to malnourished infants and young children who fail to meet expected standards of growth. Of the following, the growth parameter that is usually not affected by malnutrition is
- A. weight
- B. height
- C. weight for height ratio
- D. head circumference
Correct Answer: D
Rationale: Head circumference is less likely to be affected by short-term malnutrition because brain growth is prioritized during infancy and early childhood.
After a 3- month trail of dietary therapy, a client with type2 diabetes mellitus still has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide:
- A. 30 minutes before breakfast
- B. 30 minutes after dinner.
- C. in the midmorning
- D. at bedtime.
Correct Answer: D
Rationale: Glyburide (DiaBeta) is a sulfonylurea medication used to treat type 2 diabetes mellitus by stimulating the pancreas to release more insulin. Taking glyburide at bedtime is recommended because it helps to ensure that the medication's peak action aligns with the natural rise in blood glucose levels in the early morning hours, which can help control fasting blood glucose levels. Additionally, taking glyburide in the evening reduces the risk of hypoglycemia during the day when the client may be more active and less likely to monitor blood glucose levels closely.