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A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I plan to take this medication for 1 week.
- B. I should take an antacid with each dose of this medication.
- C. This medication may cause my blood pressure to increase.
- D. I will have my liver function tested while I am taking this medication.
Correct Answer: D
Rationale: The correct answer is D: "I will have my liver function tested while I am taking this medication." This is the correct answer because isoniazid (INH) is known to potentially cause liver toxicity. Monitoring liver function tests is crucial to detect any signs of liver damage early. Choice A is incorrect as INH treatment for tuberculosis typically lasts 6-9 months, not just 1 week. Choice B is incorrect because antacids can decrease the absorption of INH. Choice C is incorrect as INH does not typically cause an increase in blood pressure.
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A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the feet.
- B. Keep the client's knees in a flexed position while they are in bed.
- C. Massage the client's legs every 4 hr while they are awake.
- D. Limit the client's fluid intake to 2
Correct Answer: A
Rationale: Correct Answer: A - Encourage the client to perform circumduction of the feet.
Rationale: Circumduction of the feet involves moving the feet in a circular motion, which helps promote blood circulation and prevent stasis in the lower extremities. This movement aids in preventing venous thromboembolism by reducing the risk of blood clots forming in the legs postoperatively. Encouraging this activity is crucial in maintaining vascular health and preventing complications.
Summary of Incorrect Choices:
B: Keeping the client's knees in a flexed position while in bed may lead to decreased circulation and increase the risk of venous stasis.
C: Massaging the client's legs every 4 hours can dislodge blood clots and increase the risk of embolism.
D: Limiting fluid intake can lead to dehydration, which can increase the risk of clot formation due to thicker blood consistency.
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 caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse, 'I am afraid to have this procedure.' Which of the following responses should the nurse make?
- A. Are you afraid of needles that will be used during the procedure?
- B. After this procedure
- C. you will feel much better.
- D. Tell me why you are scared to have this procedure.
Correct Answer: D
Rationale: Rationale: The correct response is D because it demonstrates active listening and empathy by encouraging the client to express their fears. By asking the client to elaborate on their fears, the nurse can address specific concerns and provide appropriate support. This promotes trust and open communication between the nurse and client, leading to better outcomes.
Incorrect Responses:
A: This response assumes the fear is related to needles and does not address the client's specific concerns about the procedure.
B: This response is incomplete and does not acknowledge the client's fear.
C: This response minimizes the client's feelings and does not address the underlying fear.
Overall, these responses fail to address the client's emotional needs and may not effectively alleviate their fear or anxiety.
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Painless vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Painless vaginal bleeding. Cervical cancer can present with abnormal vaginal bleeding, which may include bleeding between periods, after intercourse, or post-menopause. This is due to the abnormal growth of cells in the cervix. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typical manifestations of cervical cancer. Diarrhea and urinary hesitancy are more commonly associated with gastrointestinal or urinary tract issues, while unexplained weight gain can be linked to various factors such as hormonal imbalances or dietary changes.
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample
- B. Check the clients' vital signs
- C. Stop the infusion
- D. Administer oxygen to the client
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client is showing signs of a transfusion reaction, which can be serious. Stopping the infusion is the first priority to prevent further complications. Vital signs should be checked next to assess the client's condition. Collecting a urine sample is not a priority in this situation. Administering oxygen may be necessary depending on the client's condition, but stopping the infusion takes precedence.