Nokea
A client with acquired immunodeficiency syndrome is admitted with a diagnosis of pneumocystis jirovecki pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based on his mental status, the priority nursing diagnosis is:
- A. Social isolation
- B. Risk for self-injury
- C. Ineffective coping
- D. Anxiety
Correct Answer: B
Rationale: The client's confusion and attempts to remove medical devices indicate a risk for self-injury, making this the priority nursing diagnosis.
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The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The nurse should reinforce teaching about which topics? Select all that apply.
- A. Not taking tetracycline with dairy products
- B. Taking tetracycline at bedtime
- C. Taking tetracycline with food
- D. Using additional contraceptive techniques
- E. Using sunblock
Correct Answer: A,D,E
Rationale: Tetracycline binds to calcium in dairy, reducing absorption. It can reduce oral contraceptive efficacy, requiring backup methods. Photosensitivity necessitates sunblock. Taking with food or at bedtime is acceptable but not critical teaching.
Which of the following medications would be least helpful for a client who is experiencing an acute attack of bronchial asthma?
- A. Cromolyn Sodium (Intal)
- B. Epinephrine (Epi-Pen)
- C. Metaproterenol (Alupent)
- D. Theophylline (Theolair)
Correct Answer: A
Rationale: Cromolyn sodium prevents asthma attacks but is not effective for acute attacks. Epinephrine, metaproterenol, and theophylline provide rapid bronchodilation.
A 2-month-old recently diagnosed with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse reinforce to the parents? Select all that apply.
- A. Apply lotion under the straps to protect the skin.
- B. Dress the child in a shirt and knee socks under the straps.
- C. Lightly massage the skin under the straps daily.
- D. Place the diaper under the straps.
- E. Remove the harness during diaper changes.
Correct Answer: B,C,D
Rationale: Shirts and socks under straps prevent chafing, daily massage promotes circulation, and diapers under straps ensure hygiene. Lotion traps moisture, risking irritation. The harness should not be removed, even for diaper changes, to maintain correction.
The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dry, shiny, hairless skin on the affected extremity
- B. warmth and redness of the affected extremity
- C. reports of pain in the affected calf
- D. edema of the affected extremity
- E. cyanosis of the affected toes
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.
The nurse is caring for a man who had a transsphenoidal hypophysectomy earlier today. He says he has to spit a lot. What nursing action is essential?
- A. Ask him to blow his nose.
- B. Do a glucose test on his mouth secretions.
- C. Have him rinse his mouth with water.
- D. Ask him if he needs an antiemetic.
Correct Answer: B
Rationale: Excessive spitting may indicate cerebrospinal fluid (CSF) leak, which contains glucose; testing secretions confirms this serious complication.