Nokea
A mother asks the nurse if she should be concerned about her child's tendency to stutter. What assessment data will be most useful in counseling the parent?
- A. Age of the child
- B. Sibling position in family
- C. Stressful family events
- D. Parental discipline strategies
Correct Answer: A
Rationale: Age of the child. Stuttering is often a normal part of language development in preschoolers, making age a critical factor.
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A client with glaucoma has been prescribed Timoptic (timolol) eye drops. Timoptic should be used with caution in the client with a history of:
- A. Diabetes
- B. Gastric ulcers
- C. Emphysema
- D. Pancreatitis
Correct Answer: C
Rationale: Timolol, a beta-blocker, can exacerbate emphysema by causing bronchoconstriction. Diabetes , ulcers , and pancreatitis are not contraindications.
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.
The nurse is caring for a client with HIV. The nurse understands that which of the following are true regarding transmission-based precautions? Select all that apply.
- A. Donning an N95 respiratory mask decreases the risk of transmitting HIV
- B. Gown, gloves, and face shield are necessary for every client encounter
- C. Neutropenic precautions are implemented based on laboratory results
- D. The client's urine is a bodily fluid that can transmit HIV
- E. The nurse should perform hand hygiene before and after providing client care
Correct Answer: C,D,E
Rationale: Neutropenic precautions depend on lab results (e.g., low white blood cell count). Urine can transmit HIV if blood is present. Hand hygiene is standard for all encounters. N95 masks are for airborne diseases, not HIV. Full PPE isn't needed unless splashing of bodily fluids is likely.
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- A. 16 year-old who had an open reduction of a fractured wrist 10 hours ago
- B. 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
- C. 72 year-old recovering from surgery after a hip replacement 2 hours ago
- D. 75 year-old who is in skin traction prior to planned hip pinning surgery.
Correct Answer: C
Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.
The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which of the following foods? Select all that apply.
- A. red meat
- B. bananas
- C. broccoli
- D. spinach
- E. kale
Correct Answer: C,D,E
Rationale: Broccoli, spinach, and kale are high in vitamin K, which can antagonize warfarin's anticoagulant effect. Consistent intake is key, but excess can reduce effectiveness. Red meat and bananas have minimal vitamin K and don't significantly affect warfarin.