Nokea
A client has been diagnosed with glossopharyngeal neuralgia. The nurse will expect the client to
- A. experience episodes of vertigo.
- B. experience difficulty moving the tongue.
- C. experience double vision.
- D. experience episodes of pain in the throat, ears, tongue, and tonsils.
Correct Answer: D
Rationale: Glossopharyngeal neuralgia causes severe pain in the throat, ears, tongue, and tonsils due to irritation of the ninth cranial nerve.
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The nurse is preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge home. Which of the following statements by the client indicates a need for further teaching by the nurse?
- A. I do not need to limit my time in public places.'
- B. I may share food from serving dishes with others at a restaurant.'
- C. I may use public restrooms.'
- D. I may donate blood.'
Correct Answer: D
Rationale: AIDS patients cannot donate blood due to HIV transmission risk. Public activities and restrooms pose minimal risk, and sharing serving dishes is safe if not directly contaminated.
Nurses must be familiar with the American Nurses Association (ANA) Code of Ethics for Nurses. The nurse understands that which ethical principle is defined as the nurse's duty to do no harm? Fill in the blank.
- A. Nonmaleficence
- B. Bneficence
- C. autonomy
Correct Answer: A
Rationale: Nonmaleficence is the ethical principle of doing no harm, a core duty in nursing practice.
The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
- A. Determine lung maturity
- B. Measure the fetal activity
- C. Show the effect of contractions on fetal heart rate
- D. Measure the well-being of the fetus
Correct Answer: D
Rationale: A nonstress test assesses fetal well-being by monitoring fetal heart rate in response to movement, particularly in high-risk pregnancies.
When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
- A. Attempt to replace the cord
- B. Place the client on her left side
- C. Elevate the client's hips
- D. Cover the cord with a dry, sterile gauze
Correct Answer: C
Rationale: Elevating the hips relieves pressure on the prolapsed cord, maintaining fetal oxygenation.
A preterm infant with sepsis is receiving Gentamycin (garamycin). Which physiological alteration places the preterm infant at increased risk for toxicity related to aminoglycoside therapy?
- A. Lack of subcutaneous fat deposits
- B. Immature central nervous system
- C. Presence of fetal hemoglobin
- D. Immaturity of the renal system
Correct Answer: D
Rationale: The immature renal system in preterm infants reduces the ability to excrete aminoglycosides like Gentamycin, increasing the risk of toxicity.