Nokea
A 9-month-old child has been diagnosed with an ear infection. The father asks what else to do to help his child. The nurse can tell the father:
- A. Your child should also take an antihistamine.'
- B. The antibiotic is the only medicine necessary.'
- C. The ear in the ears helps the discomfort.'
- D. Over-the-counter eardrops often are helpful.'
Correct Answer: B
Rationale: Antibiotics are the primary treatment for bacterial ear infections; antihistamines and eardrops are not typically recommended unless prescribed.
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An adolescent tells the school nurse she thinks she has infectious mononucleosis. The nurse should next assess the client for?
- A. Sore throat and malaise.
- B. Fatigue and weight loss.
- C. Coldlike symptoms and fever.
- D. Skin rash and abdominal pain.
Correct Answer: A
Rationale: Sore throat and malaise are hallmark symptoms of mononucleosis, requiring targeted assessment.
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minutes, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?
- A. Notify the physician.
- B. Administer a sedative.
- C. Try to elicit a positive Homan's sign.
- D. Increase the flow rate of intravenous fluids.
Correct Answer: A
Rationale: These symptoms suggest a possible pulmonary embolism, a life-threatening complication of DVT, requiring immediate physician notification.
The nurse is visiting a client who has been prescribed topical clotrimazole. The nurse should educate the client to the fact that this medication will alleviate which condition?
- A. Pain
- B. Rash
- C. Fever
- D. Sneezing
Correct Answer: B
Rationale: Clotrimazole is a topical antifungal used in the treatment of cutaneous fungal infections and will alleviate an associated rash. The nurse teaches the client that it is used for this purpose. It is not used for pain, sneezing, or fever.
You have decided to use the Dimensions Model of Health model to assess, monitor and evaluate the health status of the community. Which of these dimensions is NOT an element of this Dimensions Model of Health model?
- A. The Biophysical Dimension
- B. The Psychological and Emotional Dimension
- C. The Spiritual Dimension
- D. The Health Systems Dimension
Correct Answer: D
Rationale: The Dimensions Model of Health typically includes biophysical, psychological, social, and spiritual dimensions. The Health Systems Dimension is not a standard component of this model.
A hospice nurse is caring for a client with breast cancer and brain metastasis. The nurse is reviewing the lab report below. According to the information in the chart, what should the nurse do next?
- A. Document these results on the medical record.
- B. Report the elevated potassium level immediately.
- C. Report the elevated calcium level immediately.
- D. Refrain from reporting the results because the client is in hospice care.
Correct Answer: C
Rationale: The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide (Lasix), or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.