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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: The correct answer is B: Reduced sneezing. Decongestants work by constricting blood vessels in the nasal passages, reducing swelling and congestion, which in turn can lead to a decrease in sneezing. Increased salivation (choice A) is not a typical effect of decongestants. Increased tearing (choice C) is more commonly associated with allergies or irritants. Headache (choice D) can be a side effect of decongestants due to their impact on blood vessels, but it does not necessarily indicate effectiveness in treating allergic rhinitis.
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25-year old Francisco M., is diagnosed as having myelocytic leukemia and is admitted for chemotherapy. Francisco M.’s laboratory results indicate bone marrow depression. The nurse should encourage him to:
- A. Sleep with the head of the bed slightly
- B. Use a soft toothbrush and electric razor
- C. Drink citrus juices frequently for nourishment
- D. Increase his activity level and ambulates frequently
Correct Answer: B
Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because:
A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression.
C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding.
D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to focus the interview on the patient's needs. This step helps in gathering important information and establishing rapport. Introductions are usually done at the beginning of the interview, so it is not the next step. Explaining that the interview will be over in a few minutes can create anxiety and hinder open communication. Telling the patient about administering medications in 1 hour is not relevant at this point in the interview.
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
- A. Begin with introductions.
- B. Ask about the chief concerns or problems.
- C. Explain that the interview will be over in a few minutes.
- D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems.
Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to gather relevant information and focus the interview on the patient's needs. This step helps establish rapport and ensures the patient is actively involved in the conversation.
Incorrect Choices:
A: Beginning with introductions is important, but after setting the agenda, it is more crucial to address the patient's concerns.
C: Explaining that the interview will be over in a few minutes is not appropriate as it may rush the patient and hinder open communication.
D: Telling the patient about administering medications in 1 hour is not relevant at this stage and does not address the patient's immediate needs.
A female client age 66 is admitted ff a nephrolithomy. One of her laboratory tests reveals a urinary tract infection. Which would be the best nursing action in her case?
- A. Administer IV fluids and blood transfusions
- B. Administer narcotic analgesics as prescribed
- C. Encourage fluid intake of 3000ml/day
- D. Suggest taking herbs or spices to increase food palatability
Correct Answer: C
Rationale: Correct Answer: C - Encourage fluid intake of 3000ml/day
Rationale: Encouraging fluid intake of 3000ml/day helps to flush out bacteria from the urinary tract, reducing the risk of infection spread. Adequate hydration also prevents further stone formation.
Incorrect Choices:
A: Administering IV fluids and blood transfusions may not directly address the urinary tract infection.
B: Administering narcotic analgesics may mask symptoms but not treat the root cause of the infection.
D: Suggesting herbs or spices does not address the need for adequate fluid intake to manage the urinary tract infection.
What should a male client over age 50 do to help ensure early identification of prostate cancer?
- A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
- B. Have a transrectal ultrasound every 5 years
- C. Perform monthly testicular self-examinations, especially after age 50
- D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
Correct Answer: A
Rationale: Rationale:
1. Digital rectal exam (DRE) and PSA test are recommended by major health organizations for prostate cancer screening in men over 50.
2. DRE helps detect abnormalities in the prostate, while PSA test measures the levels of a protein produced by the prostate gland.
3. Prostate cancer can be asymptomatic in its early stages, so regular screening is crucial for early detection and treatment.
4. Transrectal ultrasound is not a primary screening method for prostate cancer.
5. Testicular self-exams are for detecting testicular cancer, not prostate cancer.
6. CBC, BUN, and creatinine levels are not specific tests for prostate cancer screening.