Nokea
A client who is postmenopausal asks the nurse how to prevent osteoporosis. Which statement should the nurse make to the client?
- A. Eat 2 ounces of cheese each day and walk a mile a day.
- B. There are no known ways to prevent osteoporosis.
- C. Do weight-bearing exercises regularly and take hormones as ordered by your physician.
- D. Take potassium supplements daily.
Correct Answer: C
Rationale: Weight-bearing exercises and hormone therapy (if prescribed) are evidence-based methods to prevent osteoporosis, unlike the other options.
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The client presents to the emergency room with a 'bull's eye' rash. Which question would be most appropriate for the nurse to ask the client?
- A. Have you found any ticks on your body?'
- B. Have you had any nausea in the last 24 hours?'
- C. Have you been outside the country in the last 6 months?'
- D. Have you had any fever for the past few days?'
Correct Answer: A
Rationale: A bull's eye rash is characteristic of Lyme disease, often caused by tick bites, making this the most relevant question.
The nurse has just received the change of shift report. Which client should the nurse assess first?
- A. A client with a supratentorial tumor awaiting surgery
- B. A client admitted with a suspected subdural hematoma
- C. A client recently diagnosed with akinetic seizures
- D. A client transferring to the neuro rehabilitation unit
Correct Answer: B
Rationale: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment to prevent deterioration.
The nurse is preparing to administer an injection to a 6-month-old when she notices a white dot in the infant's right pupil. The nurse should:
- A. Report the finding to the physician immediately
- B. Record the finding and give the infant's injection
- C. Recognize that the finding is a variation of normal
- D. Check both eyes for the presence of the red reflex
Correct Answer: A
Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or cataracts, requiring immediate reporting to the physician for further evaluation.
As serum calcium levels rise, which hormone is excreted?
- A. prolactin
- B. melatonin
- C. aldosterone
- D. parathyroid
- E. None
- F. all the above
Correct Answer: E
Rationale: Calcitonin (not listed) is secreted by the thyroid to lower high serum calcium. Parathyroid hormone (D) increases calcium. None of the options are correct.
A client has a CVP monitor in place. Which would be included in the nursing care plan for this client?
- A. Notify the physician of readings less than 3 cm or more than 8 cm of water
- B. Use the clean technique to change the dressing at the insertion site
- C. Elevate the head of the bed to 90° to obtain CVP readings
- D. The 0 mark on the manometer should align with the client's right clavicle for the readings
Correct Answer: A
Rationale: CVP readings outside 3-8 cm of water may indicate fluid imbalance or catheter issues, requiring physician notification to prevent complications.