Nokea
A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?
- A. I can take another dose after 2 minutes.
- B. I can put the tablet against my cheek and gum.
- C. I should chew the tablet before I swallow it.
- D. I should take this medication as soon as the pain begins.
Correct Answer: D
Rationale: The correct answer is D: "I should take this medication as soon as the pain begins." This is correct because nitroglycerin is a rapid-acting medication used to relieve chest pain associated with angina. Taking it at the onset of chest pain helps dilate blood vessels and improve blood flow to the heart muscle.
Choice A is incorrect because taking another dose after 2 minutes could lead to overdose and hypotension. Choice B is incorrect as the tablet should be placed under the tongue, not against the cheek and gum. Choice C is incorrect because nitroglycerin should not be chewed but allowed to dissolve under the tongue.
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A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
- A. Loss of peripheral vision
- B. Inability to smell
- C. Deviation of the tongue from midline
- D. Disequilibrium with movement
Correct Answer: D
Rationale: The correct answer is D: Disequilibrium with movement. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for both hearing and balance. Impaired function of this nerve can result in symptoms such as dizziness, vertigo, and disequilibrium with movement. This is because the vestibular branch of the nerve is crucial for maintaining balance and spatial orientation.
Choice A, loss of peripheral vision, is not related to cranial nerve VIII but rather to cranial nerve II, the optic nerve. Choice B, inability to smell, is associated with cranial nerve I, the olfactory nerve. Choice C, deviation of the tongue from midline, is a sign of dysfunction of cranial nerve XII, the hypoglossal nerve.
In summary, the correct answer is D because impaired function of the vestibulocochlear nerve (cranial nerve VIII) would result in disequilibrium with movement, while the other choices are related to different cranial
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
- A. Increase phosphorus intake
- B. Decrease carbohydrate intake
- C. Decrease protein intake
- D. Increase potassium intake
Correct Answer: C
Rationale: The correct answer is C: Decrease protein intake. Nephrotic syndrome causes protein loss through urine, leading to hypoalbuminemia and edema. Decreasing protein intake can help reduce proteinuria and decrease the workload on the kidneys. Increasing phosphorus intake (A) can worsen kidney function. Decreasing carbohydrate intake (B) is not directly related to managing nephrotic syndrome. Increasing potassium intake (D) is not recommended as it can lead to hyperkalemia in individuals with kidney issues.
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
A nurse is providing discharge teaching to a client who had a bilateral architectomy. The nurse should instruct the client to expect which of the following symptoms?
- A. Hypoglycemia
- B. Increased libido
- C. Hot flashes
- D. Increased muscle mass
Correct Answer: A
Rationale: The correct answer is A: Hypoglycemia. After a bilateral adrenalectomy, the client will have decreased cortisol production, leading to adrenal insufficiency. This can result in hypoglycemia due to decreased glucose regulation. Increased libido (B) and increased muscle mass (D) are not typical symptoms following this procedure. Hot flashes (C) are more commonly associated with menopause.
A nurse is caring for a client who is postoperative following a below-the-knee amputation. Which of the following statements made by the client indicates acceptance of their altered body image?
- A. I would like to meet with another client who has had an amputation.'
- B. I would rather not look at my stump during a dressing change.'
- C. I am glad that I no longer have to deal with my infected leg.'
- D. I understand that I will be unable to return to my job.'
Correct Answer: A
Rationale: The correct answer is A because the statement indicates the client's willingness to connect with someone who has undergone a similar experience, showing acceptance and readiness to learn from others in similar situations. This demonstrates the client's acknowledgment of their altered body image and a proactive approach towards coping with it positively. Choice B reflects avoidance behavior, not acceptance. Choice C focuses on the relief of pain rather than acceptance of body image changes. Choice D suggests resignation rather than acceptance.