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A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
- A. Blurred vision
- B. Severe headache
- C. Oriented to person, place, and year
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Severe headache. Meningitis commonly presents with severe headache due to inflammation of the meninges. This is a classic symptom and should be expected during assessment. Blurred vision (A) is not a typical finding in meningitis. Being oriented to person, place, and year (C) is a sign of intact mental status, which may not be present in someone with meningitis. Bradycardia (D) is not a common finding in meningitis; tachycardia is more likely due to the body's response to infection.
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A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?
- A. Take the medication with orange juice.
- B. Take the medication between meals.
- C. Take the medication on an empty stomach.
- D. Take the medication with milk.
Correct Answer: D
Rationale: The correct answer is D: Take the medication with milk. Betamethasone can cause stomach irritation, so taking it with milk can help reduce this side effect. Milk coats the stomach lining, providing a protective barrier. This helps to minimize the risk of gastrointestinal upset.
A: Taking the medication with orange juice is not recommended as it can increase stomach irritation due to its acidity.
B: Taking the medication between meals may not provide the same protective effect on the stomach lining as taking it with milk.
C: Taking the medication on an empty stomach can increase the risk of gastrointestinal irritation and should be avoided.
E, F, G: These options are not relevant to the administration of betamethasone.
A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
- A. Using the palm of the hand, feel for lumps using a circular motion.
- B. Expect some breast dimpling or discharge with age.
- C. Breasts can be examined in the shower with soapy hands.
- D. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.
Correct Answer: C
Rationale: The correct answer is C: Breasts can be examined in the shower with soapy hands. This instruction is important because warm water and soap help to make the examination more comfortable and easier to detect any abnormalities. By examining the breasts in the shower, the individual can incorporate BSE into their routine without it feeling like a separate task. This method also allows for better coverage and thorough examination of the entire breast tissue.
Choice A is incorrect because using the palm of the hand in a circular motion may not be as effective in detecting lumps compared to using the fingertips. Choice B is incorrect as breast dimpling or discharge are not normal signs of aging, and should be reported to a healthcare provider. Choice D is incorrect as performing BSE at specific times in the menstrual cycle is not necessary.
A nurse is attending a social event when another guest coughs weakly once, grasps his throat, and cannot talk. Which of the following actions should the nurse take?
- A. Perform the Heimlich maneuver.
- B. Slap the client on the back several times.
- C. Assist the client to the floor and begin mouth-to-mouth resuscitation.
- D. Observe the client before taking further action.
Correct Answer: A
Rationale: The correct answer is A: Perform the Heimlich maneuver. This action is appropriate for a choking individual who is unable to speak, cough weakly, and grasp their throat, indicating a partial airway obstruction. The Heimlich maneuver is designed to dislodge the obstruction by applying abdominal thrusts. This is the most effective intervention in this scenario to clear the airway and restore breathing. Slapping the client on the back (B) may not effectively remove the obstruction. Mouth-to-mouth resuscitation (C) is not indicated for a conscious choking person. Observing the client (D) without taking immediate action can lead to a worsening situation.
A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
- A. Verify the provider’s prescription to discontinue the tube.
- B. Disconnect the tube from the wall suction.
- C. Perform hand hygiene.
- D. Provide mouth care to the client.
Correct Answer: A
Rationale: The correct answer is A: Verify the provider’s prescription to discontinue the tube. This is the first step because removing an NG tube without a prescription could lead to serious complications. The nurse must ensure that it is safe and appropriate to remove the tube as per the provider's orders. Disconnecting the tube from the wall suction (B) should only be done after verifying the prescription. Performing hand hygiene (C) and providing mouth care to the client (D) are important steps in the process but should come after confirming the prescription.
A nurse is assessing a client who is admitted for elective surgery and has a history of Addison’s disease. Which of the following findings should the nurse expect?
- A. Purple striations
- B. Hirsutism
- C. Hyperpigmentation
- D. Intention tremors
Correct Answer: C
Rationale: The correct answer is C: Hyperpigmentation. Addison's disease is characterized by adrenal insufficiency, leading to decreased production of cortisol and aldosterone. This results in increased production of ACTH, which can cause hyperpigmentation, especially in sun-exposed areas. Purple striations (A) are seen in Cushing's syndrome, not Addison's. Hirsutism (B) is excessive hair growth, commonly seen in conditions like polycystic ovary syndrome, not Addison's. Intention tremors (D) are associated with cerebellar dysfunction, not typically seen in Addison's.