Nokea
A client has had hoarseness for more than 2 weeks. The nurse should:
- A. Refer to a health care provider for a prescription for an antibiotic.
- B. Instruct the client to gargle with salt water at home.
- C. Assess the client for dysphagia.
- D. Instruct the client to take a throat analgesic.
Correct Answer: C
Rationale: Persistent hoarseness may indicate laryngeal pathology, including cancer; assessing for dysphagia (difficulty swallowing) helps evaluate severity and urgency. Antibiotics are inappropriate without a bacterial diagnosis. Gargling or analgesics may mask symptoms without addressing the cause.
You may also like to solve these questions
When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply.
- A. The drug can be used if the person is allergic to aspirin.
- B. Acetaminophen does not affect platelet aggregation.
- C. This drug causes little or no gastric distress.
- D. Acetaminophen exerts a strong antiinflammatory effect.
- E. The client should have the International Normalized Ratio (INR) checked regularly.
Correct Answer: A,B,C
Rationale: Acetaminophen is safe for aspirin allergies, does not affect platelets, and causes minimal gastric distress. It has weak anti-inflammatory effects and does not require INR monitoring.
When a client cannot read or write but is of sound mind, the nurse should read the consent to the client in the presence of two witnesses and:
- A. Have the client's next-of-kin sign the consent.
- B. Have the client put an 'X' on the signature line.
- C. Have a court appoint a guardian for the client.
- D. Have a hospital quality management coordinator sign for the client.
Correct Answer: B
Rationale: For a client of sound mind who cannot read/write, reading the consent and having the client mark an 'X' with two witnesses ensures legal informed consent without requiring a guardian.
Which symptom suggests worsening neurological status in a client with a head injury?
- A. Improved orientation.
- B. Decreased pulse rate.
- C. Stable blood pressure.
- D. Mild fatigue.
Correct Answer: B
Rationale: Decreased pulse rate (bradycardia) may indicate increased intracranial pressure, a sign of worsening neurological status.
A client with uric acid stones is prescribed a low-purine diet. Which food is allowed?
- A. Liver.
- B. Chicken.
- C. Apples.
- D. Sardines.
Correct Answer: C
Rationale: Apples are low in purines, suitable for a uric acid stone diet.
Which of the following clients is most at risk for potential hazards from the surgical experience?
- A. A 68-year-old client.
- B. A 48-year-old client.
- C. A 30-year-old client.
- D. A 13-year-old client.
Correct Answer: A
Rationale: The 68-year-old client is most at risk due to age-related declines in organ function, slower recovery, and higher likelihood of comorbidities, increasing surgical complications.