Nokea
A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which supplement might help synchronize the body to environmental time?
- A. Evening primrose
- B. Ginseng
- C. Melatonin
- D. St. John wort
Correct Answer: C
Rationale: Melatonin helps regulate sleep-wake cycles and can mitigate jet lag.
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The nurse is caring for a 67-year-old client with postherpetic neuralgia who has a new prescription for amitriptyline. Which of the following actions would be a priority for the nurse to take?
- A. Schedule frequent rest periods for the client.
- B. Encourage the client to increase the intake of fluids.
- C. Instruct the client to stand up slowly from a sitting position.
- D. Remind the client to wear sunglasses when spending time outdoors.
Correct Answer: C
Rationale: Amitriptyline can cause orthostatic hypotension, making slow position changes a priority to prevent falls.
A nurse has administered several blood transfusions over 3 days to a 12 year-old client with Thalassemia. What lab value should the nurse monitor closely during this therapy?
- A. Hemoglobin
- B. Red Blood Cell Indices
- C. Platelet count
- D. Neutrophil percent
Correct Answer: A
Rationale: Hemoglobin should be in a therapeutic range of approximately 10 g/dl (100 g). This level is low enough to foster the patient’s own erythropoiesis without enlarging the spleen.
The nurse reinforces teaching for the parents of a child with impetigo. Which of the following statements by a parent indicates correct understanding of teaching? Select all that apply.
- A. I should wash my hands before and after touching the infected area.
- B. I will clean the infected area with alcohol before applying the antibiotic ointment.
- C. I will separate my child's clothing from other laundry and wash them with hot water.
- D. My child's fingernails should be kept short and well-filed.
- E. The infection could easily spread to other children who come in contact with my child.
Correct Answer: A,C,D,E
Rationale: Hand hygiene, separating laundry, keeping nails short, and recognizing the contagious nature of impetigo are correct. Cleaning with alcohol is inappropriate as it may irritate the skin.
A woman who is pregnant for the first time asks the nurse when during pregnancy is the best time to take Lamaze classes. What should the nurse respond?
- A. During the first trimester
- B. During the second trimester
- C. During the third trimester
- D. Whatever fits into your schedule
Correct Answer: B
Rationale: The second trimester is ideal for Lamaze classes, as it allows time to learn techniques before labor while avoiding early pregnancy discomforts and late-term fatigue.
The client is unable to adequately bathe himself because he has dressings on his hands that cannot get wet. What is the most appropriate nursing diagnosis for this assessment finding?
- A. Risk for infection
- B. Deficient knowledge
- C. Acute pain related to specific illness or disease process
- D. Self-care deficit (bathing)
Correct Answer: D
Rationale: Inability to bathe due to hand dressings indicates a self-care deficit in bathing, the most specific nursing diagnosis.