Nokea
A 68-year-old man is diagnosed with myasthenia gravis. The nurse instructs the client about his disease. Which of the following statements, if made by the client to the nurse, indicates the need for further teaching?
- A. I should not drink alcoholic beverages.
- B. I should not go places that are crowded.
- C. I should try to stay calm.
- D. I should use my hot tub daily.
Correct Answer: D
Rationale: Hot tubs cause heat exposure, which can exacerbate myasthenia gravis symptoms, indicating a need for further teaching. Options A, B, and C are correct: alcohol worsens symptoms, crowds increase infection risk, and stress can trigger exacerbations.
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The nurse is screening an eight-month-old girl in a well-baby clinic. The nurse would be MOST concerned if the infant's mother made which of the following statements?
- A. My daughter has almost doubled her birth weight.
- B. When I walk in the room my child smiles at me.
- C. When she is around her grandpa, my child cries.
- D. My daughter can't quite say Mama yet.
Correct Answer: A
Rationale: An eight-month-old should have doubled birth weight by 5–6 months; 'almost doubled' suggests growth delay, requiring evaluation. Options B, C, and D are normal behaviors.
The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to
- A. restrict visitors to immediate family
- B. avoid arousal of the client except for family visits
- C. keep client's hips flexed at no less than 90 degrees
- D. apply a warming blanket for temperatures of 98 degrees Fahrenheit or less
Correct Answer: A
Rationale: restrict visitors to immediate family. Maintaining a quiet environment will assist in minimizing cerebral rebleeding. When family visit, the client should not be disturbed. If the client is awake, topics of a general nature are better choices for discussion than topics that result in emotional or physiological stimulation.
An adult had exploratory surgery and postoperatively had an exacerbation of asthma. The client is on a rebreathing mask and seems upset and angry. What is the best nursing approach?
- A. Ask the physician for an order for lorazepam (Ativan).
- B. Spend some time with the client.
- C. Ask the family to have someone stay with the client.
- D. Apply wrist restraints.
Correct Answer: B
Rationale: Spending time with the client addresses emotional distress, calming them without medication or restraints, supporting asthma management.
Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items?
- A. The client has complaints of not sleeping well for the past week
- B. The family wants to discontinue the home meal service, meals on wheels
- C. The urine in the client has been cloudy for the last 2 days
- D. The partner says the client has slower days every other day
Correct Answer: C
Rationale: Home health aides need to report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs which require immediate action and follow-up. The color of the urine requires follow-up evaluation.
A 23-year-old man with Addison's disease comes to the health clinic. The nurse should expect the client to report that his skin has become
- A. darker and more pigmented.
- B. ruddy and oily.
- C. puffy and scaly.
- D. pale and dry.
Correct Answer: A
Rationale: increase in melanocyte-stimulating hormone results in 'eternal tan'