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A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?
- A. Explain that she can't give medical advice
- B. Inform the neighbor that she might require surgery
- C. Advise the neighbor to seek medical attention
- D. Tell the neighbor that she'll be fine because she was able to get through the night
Correct Answer: C
Rationale: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.
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During a home visit, the nurse observes a man who is recovering from a left total hip replacement. Which observation indicates that the client understands his care?
- A. He is sitting in a soft, overstuffed easy chair.
- B. He bends over to pat his cat.
- C. He crosses his legs when sitting.
- D. He holds the cane in his right hand when walking.
Correct Answer: D
Rationale: Holding the cane in the right hand (opposite the affected left hip) provides support and balance, indicating proper care understanding. Soft chairs, bending, or crossing legs risk hip dislocation.
The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is
- A. touching the trapezius muscle or arm firmly
- B. pinching any body part
- C. shaking a limb vigorously
- D. rubbing the sternum
Correct Answer: D
Rationale: rubbing the sternum. The purpose is to assess the non-responsive client's reaction to a painful stimulus after less noxious methods have been tried.
A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone (TSH) level. On initial assessment, the nurse would anticipate which of the following findings?
- A. Lethargy
- B. Heat intolerance
- C. Diarrhea
- D. Skin eruptions
Correct Answer: A
Rationale: Lethargy. Hypothyroidism slows metabolism, leading to symptoms like lethargy, constipation, and cold intolerance.
A client with seizure disorder is to receive Dilantin (Phenytoin) and Phenobarbital. The nurse knows that when she administers Phenobarbital and Dilantin (Phenytoin):
- A. A larger dose of Phenobarbital might be required.
- B. A smaller dose of Phenobarbital might be required.
- C. There will be no need to alter the amount of Phenobarbital.
- D. The two drugs cannot be given together.
Correct Answer: A
Rationale: Phenytoin induces liver enzymes, potentially reducing phenobarbital levels, so a larger dose of phenobarbital may be needed.
Signs of impaired breathing in infants and children include all of the following except:
- A. nasal flaring.
- B. grunting.
- C. seesaw breathing.
- D. quivering lips.
Correct Answer: D
Rationale: Nasal flaring, grunting, and seesaw breathing are signs of respiratory distress in infants and children. Quivering lips are not a recognized indicator of impaired breathing. Physiological Adaptation