Nokea
A 6-year-old was just diagnosed with pediculosis capitis. Which comment by the mother of the child indicates to the nurse in the physician's office that she does not understand how this condition is spread?
- A. I need to wash all his bed sheets in hot water.'
- B. I will call the school nurse and tell her.'
- C. I think he got this at our neighbor's house; it's very dirty.'
- D. I will tell my son not to wear other children's hats.'
Correct Answer: C
Rationale: Blaming a dirty house misrepresents lice transmission, which occurs via direct head-to-head contact or sharing items, indicating misunderstanding.
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The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse's teaching?
- A. I am glad that I can continue to take my kava supplement each morning.
- B. If I can't sleep, I will take some melatonin with my evening dose of clonazepam.
- C. If I feel restless, I can put some drops of lavender essential oil in a diffuser to calm myself.
- D. When my anxiety is getting really intense, I will drink some valerian tea to help me relax.
Correct Answer: C
Rationale: Lavender essential oil in a diffuser is a safe, non-pharmacological method to reduce restlessness, compatible with clonazepam without risk of interaction.
The client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to 'reach the itch.' What is the nurse's priority action?
- A. Offer the client a straw to reach the itch instead of a lead pencil
- B. Perform a peripheral neurovascular check of the casted extremity
- C. Pour a generous amount of baby powder or corn starch in the cast to reach the itch
- D. Review appropriate itch relief technique using the cool setting of a hair dryer
Correct Answer: D
Rationale: Using a hair dryer on a cool setting is a safe and effective way to relieve itching without risking skin damage or cast integrity, unlike inserting objects or powders.
Vital signs
Temperature 98.2 F (36.7 C)
Blood pressure 108/72 mm Hg
Heart rate 62/min
Respirations 16/min
SpO2 96% on room air
A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply.
- A. How to take own pulse
- B. Monitoring daily weight
- C. Need for monthly International Normalized Ratio testing
- D. Need to increase foods high in potassium
- E. Reduction of sodium in diet
- F. Use of home oxygen
Correct Answer: A,B,E
Rationale: Taking pulse (A), monitoring weight (B), and reducing sodium (E) help manage heart failure by tracking symptoms, detecting fluid retention, and preventing exacerbation.
The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up?
- A. Black, tarry stool
- B. Bright red-streaked stool
- C. Light gray clay-colored stool
- D. Small, dry, rocky stool
Correct Answer: A
Rationale: Black, tarry stool (melena) indicates upper gastrointestinal bleeding, a serious complication in cirrhosis due to portal hypertension or varices, requiring immediate intervention.
The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required?
- A. I need to have the entire house treated by pest control to ensure the bed bugs are gone.
- B. I should concentrate on alleviating scratching as it can cause further complications.
- C. My other family members and pets are at risk of bed bug bites.
- D. This must have happened because I did not wash the bed sheets this week.
Correct Answer: D
Rationale: Bed bug infestations are not caused by unwashed sheets but by exposure to infested environments. This misconception indicates a need for further teaching about bed bug transmission and prevention.