Nokea
A client's vision is to be evaluated using the Ishihara exam. The nurse recognizes that the client will be checked for:
- A. Macular degeneration
- B. Astigmatism
- C. Color blindness
- D. Glaucoma
Correct Answer: C
Rationale: The Ishihara exam tests for color blindness by assessing color perception. It does not evaluate macular degeneration, astigmatism, or glaucoma.
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The nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true with regards to tardive dyskinesia?
- A. TD develops within hours or years of continued antipsychotic drug use in people under 20 and over 30
- B. It can occur in clients taking antipsychotic drugs longer than 2 years
- C. Tardive dyskinesia occurs within minutes of the first dose of antipsychotic drugs and is reversible
- D. TD can easily be treated with anticholinergic drugs
Correct Answer: B
Rationale: Tardive dyskinesia is an extrapyramidal side effect that typically develops after prolonged use of antipsychotic drugs, often longer than 2 years, and is not easily reversible or treated with anticholinergics.
A new mother has some questions about PKU.
Which of the following statements made by the nurse is correct regarding PKU?
- A. An amniocentesis is required prior to delivery.
- B. PKU test is performed soon after birth.
- C. PKU is preventable if the mother eats adequate amount of protein during pregnancy.
- D. The effects of PKU are irreversible
Correct Answer: B
Rationale: The PKU test is performed shortly after birth to detect phenylalanine levels.
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
- A. Administration of cough suppressants
- B. Increasing oral fluid intake to 3000 cc per day
- C. Maintaining bed rest with bathroom privileges
- D. Performing chest physiotherapy twice a day
Correct Answer: B
Rationale: Increasing oral fluid intake to 3000 cc per day. Secretion removal is enhanced with adequate hydration, which thins and liquefies secretions.
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
- A. The client's urine test is positive for glucose and acetone.
- B. The client has 1+ pedal edema in both feet at the end of the day.
- C. The client complains of an increase in vaginal discharge.
- D. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: Positive urine glucose and acetone suggest gestational diabetes mellitus (GDM), which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Pedal edema (B), increased vaginal discharge (C), and diaphragmatic pressure (D) are common in late pregnancy and not typically concerning unless accompanied by other symptoms.
You were about to give AM care, a patient requested for pain medication after returning from surgery 24 hours ago.
What do you do first?
- A. Take VS, assess pain, do AM care.
- B. Give medication, take VS, assess pain, do AM care.
- C. Take VS, give medication, do AM care.
- D. Perform AM care, give medication, assess pain.
Correct Answer: C
Rationale: Vital signs must be assessed before administering pain medication to ensure the patient is stable and to establish a baseline.