Nokea
A nurse is planning to complete a physical examination of a toddler. Which approach is an appropriate intervention by the nurse?
- A. Encourage the parent to be involved with the child
- B. Engage in physical contact by removing the toddler's outer clothing first
- C. Have medical equipment lying on a counter within view
- D. Perform an examination in a head-to-toe order
Correct Answer: A
Rationale: Parental involvement reduces toddler anxiety during exams. Removing clothing first, visible equipment, or strict head-to-toe order may increase distress.
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The nurse is teaching an elderly client how to use MDIs (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication?
- A. Nebulized treatments for home care
- B. Adding a spacer device to the MDI canister
- C. Asking a family member to assist the client with the MDI
- D. Request a visiting nurse to follow the client at home
Correct Answer: B
Rationale: If the client is not using the MDI properly, the medication can get trapped in the upper airway, resulting in dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth.
The client recently admitted to the assisted living center has impaired vision related to primary open-angle glaucoma. Select the graphic that best illustrates the effects of glaucoma on the client's vision.
Correct Answer: B
Rationale: Glaucoma causes peripheral vision loss (tunnel vision), best depicted by a graphic showing a narrowed visual field. Specific graphic not provided.
What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline (Pamelor)?
- A. Symptom relief occurs in a few days
- B. Alcohol use is to be avoided
- C. Medication must be stored in the refrigerator
- D. Episodes of diarrhea can be expected
Correct Answer: B
Rationale: Alcohol potentiates the action of tricyclic antidepressants.
Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)?
- A. Direct sunlight
- B. Foods containing tyramine
- C. Foods fermented with yeast
- D. Canned citrus fruit drinks
Correct Answer: A
Rationale: Direct sunlight. Phenothiazines increase sensitivity to the sun, making clients especially susceptible to sunburn.
The nurse is caring for clients who are having the following procedures. Which client should be asked about allergies to shellfish?
- A. The client who is having an arthroscopy
- B. The client who is having an arthrocentesis
- C. The client who is having a myelogram
- D. The client who is having an electromyogram (EMG)
Correct Answer: C
Rationale: Myelograms often use iodine-based contrast; shellfish allergies may indicate iodine sensitivity, requiring verification. Arthroscopy, arthrocentesis, and EMG do not typically involve contrast.