Nokea
A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for:
- A. Vertigo.
- B. Facial paralysis.
- C. Impaired vision.
- D. Difficulty swallowing.
Correct Answer: A
Rationale: Streptomycin can damage the eighth cranial nerve (vestibulocochlear), causing vertigo or hearing loss. Facial paralysis, impaired vision, and difficulty swallowing are associated with other cranial nerves.
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Which of the following should be included in the teaching plan for a cancer client who is experiencing thrombocytopenia? Select all that apply.
- A. Use an electric razor.
- B. Use a soft-bristle toothbrush.
- C. Avoid frequent flossing for oral care.
- D. Include an over-the-counter nonsteroidal anti-inflammatory (NSAID) daily for pain control.
- E. Monitor temperature daily.
- F. Report bleeding, such as nosebleed, petechiae, or melena, to a health care professional.
Correct Answer: A,B,C,F
Rationale: Thrombocytopenia increases bleeding risk, so using an electric razor (A), soft-bristle toothbrush (B), avoiding flossing (C), and reporting bleeding (F) are critical to prevent and monitor bleeding complications. NSAIDs (D) are contraindicated, and temperature monitoring (E) is unrelated to thrombocytopenia.
When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
- A. Decreased blood volume
- B. Increase in muscular activity
- C. Increased venous pressure
- D. Increased arterial pressure
Correct Answer: C
Rationale: Bilateral ankle edema in PVD is often due to increased venous pressure from venous insufficiency or right-sided heart failure, which impairs venous return and causes fluid to pool in the lower extremities. Decreased blood volume or increased muscular activity does not cause edema, and arterial pressure is not directly related.
A nurse is teaching a client about cystoscopy preparation. What instruction should be included?
- A. Fast for 8 hours before the procedure.
- B. Drink plenty of water before the test.
- C. Expect to stay overnight in the hospital.
- D. Empty the bladder before the procedure.
Correct Answer: D
Rationale: Emptying the bladder ensures a clear view during cystoscopy and reduces discomfort.
The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate?
- A. Peripheral edema.
- B. Ascites.
- C. Anorexia.
- D. Jaundice.
Correct Answer: D
Rationale: Jaundice (D) is a common early sign of cirrhosis due to impaired bilirubin metabolism. Peripheral edema (A) and ascites (B) occur later. Anorexia (C) is less specific.
The nurse is reviewing a client's chart and notes a discrepancy in the TPN order. Which action should the nurse take first?
- A. Adjust the infusion rate to match the order.
- B. Contact the prescribing physician for clarification.
- C. Continue the current infusion rate.
- D. Document the discrepancy in the client's chart.
Correct Answer: B
Rationale: Contacting the prescribing physician for clarification is the first action to resolve a discrepancy in a TPN order, ensuring safety and accuracy. Adjusting the rate, continuing the current rate, or documenting without clarification risks errors. CN: Safety and infection control; CL: Synthesize