Nokea
A client with bipolar disorder is taking lithium to control symptoms. Which of the following statements indicates the need for further education?
- A. I need to have regular tests for thyroid function.
- B. Once I'm stabilized, I won't need further testing.
- C. I should avoid taking ibuprofen.
- D. It's important for me to avoid dehydration.
Correct Answer: B
Rationale: Lithium requires ongoing monitoring (B is incorrect), as levels and side effects need regular checks. Thyroid tests (A), avoiding ibuprofen (C), and hydration (D) are correct.
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Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi or gurgling) indicate mucus obstruction, making suctioning necessary to clear the airway.
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused. Which of the following responses by the nurse is MOST appropriate?
- A. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
- B. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
- C. Ignore the patient when she exhibits attention-seeking behavior.
- D. Rotate the staff so the patient will learn to relate to more than one nurse.
Correct Answer: B
Rationale: reward nonseeking attention behaviors by giving the patient unsolicited attention
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- A. Likes to play football
- B. Drinks carbonated drinks
- C. Has two sisters
- D. Is taking acetaminophen for pain
Correct Answer: A
Rationale: Playing football poses a high risk of fractures in osteogenesis imperfecta due to brittle bones, causing significant concern.
The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?
- A. Treatment is not recommended for children less than 10 years of age.
- B. Bed linens should be washed in hot water.
- C. Medication therapy will continue for 1 year.
- D. Intravenous antibiotic therapy will be ordered.
Correct Answer: B
Rationale: Washing bed linens in hot water helps eliminate lice and nits, which is a key part of treatment for pediculosis capitis.
A client with alcoholism has been instructed to increase his intake of thiamine. The nurse knows the client understands the instructions when he selects which food?
- A. Roast beef
- B. Broiled fish
- C. Baked chicken
- D. Sliced pork
Correct Answer: D
Rationale: Sliced pork is a rich source of thiamine (vitamin B1), which is critical for preventing Wernicke's encephalopathy in clients with alcoholism.