Nokea
A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action?
- A. Encourage frequent mouth care
- B. Cleanse the tongue and mouth with glycerin swabs
- C. Obtain a soft diet for the client
- D. Administer a topical analgesic per PRN protocol.
Correct Answer: D
Rationale: Administering a topical analgesic provides immediate pain relief, allowing the client to tolerate mouth care and other interventions.
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X-linked conditions include:
- A. Duchenne muscular dystrophy
- B. Hypophosphataemic rickets
- C. Huntington's chorea
- D. Phenylketonuria
Correct Answer: A
Rationale: Duchenne muscular dystrophy is an X-linked recessive disorder caused by mutations in the dystrophin gene.
Surgical repair of VSD should be considered at the time of diagnosis
- A. small supracristal VSD
- B. VSD with heart failure
- C. hemodynamically restrictive VSD
- D. significant VSD
Correct Answer: B
Rationale: Significant or symptomatic VSDs warrant early surgical intervention.
Recognized features in Ehlers-Danlos syndrome include:
- A. Mutation in fibrillin gene
- B. Short stature
- C. Keratoconus
- D. Easy scarring
Correct Answer: D
Rationale: Easy scarring: Ehlers-Danlos syndrome is a connective tissue disorder characterized by hyperelastic skin, joint hypermobility, and easy bruising and scarring.
A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement?
- A. Measure urine output hourly to assess for rental perfusion
- B. Request a prescription for pain medication
- C. Use an automated BP machine to monitor for hypotension
- D. Provide a quiet environment with low lighting
Correct Answer: C
Rationale: Monitoring blood pressure is crucial after administering an antihypertensive to ensure the client does not become hypotensive.
A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first?
- A. Notify the healthcare provider
- B. Assure the client that such feelings occur with wound infections
- C. Visualize the abdominal incision
- D. Obtain sterile towels soaked in saline
Correct Answer: C
Rationale: Visualizing the incision helps determine if dehiscence or evisceration has occurred, which requires immediate intervention.