Nokea
A client is being treated for severe pediculosis. The nurse should instruct the client to treat the problem in the eyebrows and eyelashes by:
- A. Applying petroleum jelly to lashes and brows three to four times a day.
- B. Applying a pediculicide with a cotton-tipped swab three to four times a day.
- C. Applying lindane ointment to the lashes and eyebrows three times a day.
- D. Applying bacitracin ointment to the lashes and brows three times a day.
Correct Answer: A
Rationale: Petroleum jelly smothers lice in the eyebrows and eyelashes, a safe and effective treatment for this sensitive area, unlike pediculicides or antibiotics.
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Which of the following is NOT an essential component of a restraint order?
- A. Informed consent for the restraint
- B. The reason for the restraint
- C. The type of restraint to be used
- D. Client behaviors that necessitated the restraints
Correct Answer: A
Rationale: A restraint order requires the reason , type , and client behaviors necessitating the restraint . Informed consent is not typically required for restraints, as they are used in emergencies or for safety.
The nurse is caring for a client with a spinal cord injury at the T4 level. Which of the following findings indicates autonomic dysreflexia?
- A. Bradycardia and hypertension.
- B. Tachycardia and hypotension.
- C. Fever and chills.
- D. Hypoxia and cyanosis.
Correct Answer: A
Rationale: Autonomic dysreflexia presents with bradycardia and hypertension due to unopposed sympathetic stimulation below the injury level.
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
- A. Symmetrical chest movement.
- B. Tracheal deviation to the affected side.
- C. Dull percussion note on the affected side.
- D. Absent breath sounds on the affected side.
Correct Answer: B,D
Rationale: Tracheal deviation to the unaffected side and absent breath sounds on the affected side are hallmark signs of tension pneumothorax due to mediastinal shift and lung collapse.
A client diagnosed with chronic kidney disease (CKD) has learned about managing diet and fluid restriction between dialysis treatments. The nurse determines that the client is compliant with the therapeutic regimen when the assessment demonstrates a weight gain of no more than how many kilograms between hemodialysis treatments?
- A. 0.5 to 0.9 kg
- B. 1 to 1.5 kg
- C. 2 to 4 kg
- D. 5 to 6 kg
Correct Answer: B
Rationale: The primary health care provider will prescribe the amount of fluid that the client is allowed to gain between dialysis treatments, but usually a limit of 1 to 1.5 kg of weight gain between dialysis treatments helps prevent hypotension that tends to occur during dialysis with the removal of larger fluid loads. The nurse determines that the client is compliant with fluid restriction if this weight gain is not exceeded.
Select the hazard of immobility that is accurately paired with an appropriate expected outcome of care that the nurse provides to prevent this complication.
- A. Bone demineralization: Turning and positioning every 2 hours
- B. Urinary stasis: The client will consume 1,000 mL of oral fluids per day
- C. Muscle atrophy: The client will perform range of motion exercises at least 3 times a day
- D. Hypercalcemia: Maintaining fluid intake of 1,000 mL per day
Correct Answer: C
Rationale: Range of motion exercises help prevent muscle atrophy by maintaining muscle strength and function in immobile clients.