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A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
- A. Increased salivation
- B. Reduced sneezing
- C. Increased tearing
- D. Headache
Correct Answer: B
Rationale: A decongestant is a medication often used to relieve nasal congestion and reduce allergy symptoms such as sneezing. If a client with allergic rhinitis has experienced reduced sneezing during a follow-up visit after taking a decongestant, it suggests that the medication has been effective in helping to alleviate their symptoms. Increased salivation, increased tearing, and headache are not typical indicators of the effectiveness of a decongestant for allergic rhinitis.
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A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care?
- A. Avoiding using a soap on the irradiated areas
- B. Applying talcum powder to the irradiated areas daily after bathing
- C. Wearing a lead apron during direct contact with the client
- D. Removing thoracic skin markings after each radiation treatment
Correct Answer: A
Rationale: The correct intervention that should be part of the plan of care for a client at risk for impaired skin integrity due to external radiation is avoiding using a soap on the irradiated areas. Soap can be drying to the skin and may exacerbate skin reactions caused by radiation therapy. It is important to keep the skin in the radiation field clean, but avoiding soap will help prevent further irritation and damage to the skin. Instead, a gentle cleanser recommended by the healthcare provider should be used to clean the irradiated areas. Additionally, maintaining good hydration and moisturizing the skin as recommended by the healthcare team can also help minimize skin reactions.
You are evaluating a 2-year-old boy with multiple bruises. Physical examination is unremarkable apart from multiple bruising areas. Lab investigations including coagulation profile are normal. Of the following, bruises that are LEAST likely suggestive of physical abuse is
- A. bruises over the neck
- B. looped extension cord marks on the body
- C. bruises over bony prominences
- D. bruising of the torso
Correct Answer: C
Rationale: Bruises over bony prominences are common in toddlers due to falls and rough play, whereas bruises in unusual locations like the neck or torso are more suspicious for abuse.
The birthweight usually quadruples by the age of
- A. 1.5 yr
- B. 2 yr
- C. 2.5 yr
- D. 3 yr
Correct Answer: B
Rationale: Birthweight typically quadruples by 2 years of age.
An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
- A. Take the client vital signs
- B. Insert a large bore IV line
- C. Check the lungs for equal breath sounds bilaterally
- D. Perform a neurologic check using the Glasgow scale
Correct Answer: B
Rationale: The first action the nurse should take upon the arrival of the adult who suffered a diving accident and is intubated and on a backboard with a cervical collar is to insert a large bore IV line. This is a priority because the person may require urgent fluid resuscitation or medication administration, and having IV access is crucial for immediate intervention in trauma cases. After establishing IV access, other assessments such as vital signs, lung sounds, and neurological checks can follow.
A patient with a new diagnosis of lymphoma is experiencing fatigue. Which of the ff. is the best way to assess her fatigue?
- A. Observe her activity level
- B. Have her rate her fatigue on a scale of 0 to
- C. Monitor for changes in vital signs 10
- D. Monitor hemoglobin and hematocrit values
Correct Answer: B
Rationale: The best way to assess a patient's fatigue is to have her rate her fatigue on a scale of 0 to 10. Fatigue is primarily a subjective symptom, and patients are the best source of information regarding their own levels of fatigue. Using a standardized scale allows for a more quantitative assessment of the severity of the fatigue experienced by the patient. This can also help in monitoring changes in fatigue over time and evaluating the effectiveness of interventions aimed at managing fatigue. While observing the patient's activity level (choice A) can provide some information, it may not always accurately reflect the subjective experience of fatigue. Monitoring for changes in vital signs (choice C) and assessing hemoglobin and hematocrit values (choice D) can be important in evaluating overall health status and potential causes of fatigue, but they do not directly assess the patient's subjective experience of fatigue.