A spansule is ordered twice a day for a client in the outpatient clinic. What should the nurse teach the client about taking a spansule?
- A. Take the spansule before breakfast and dinner.
- B. If the spansule is difficult to swallow, open it up and put the contents in food.
- C. Spansules should be taken at 12-hour intervals.
- D. Spansules can safely be cut for partial doses.
Correct Answer: C
Rationale: Spansules are time-release capsules, requiring 12-hour intervals for consistent drug release. Opening, cutting, or meal-based timing disrupts their mechanism.
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A school-aged child who was diagnosed two weeks ago with hepatitis A.
Which of the following responses by the nurse is BEST?
- A. You must isolate your child at home for two more weeks.
- B. Why don't you speak with the physician about this matter?
- C. Your child may return to school this week.
- D. Your child may return to school in 2 weeks but cannot participate in sports.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) communicable for 2-3 weeks before onset of jaundice and about 1 week after onset of jaundice (2) passing the buck (3) correct-type A hepatitis is not infectious within a week or so after the onset of jaundice, child can return to school (4) can return to school, activity at that time depends on the child's energy level
A 34-year-old multipara comes to the prenatal clinic during her fifth month of pregnancy. The client complains to the nurse that her breasts are sensitive and sore.
Which of the following suggestions by the nurse is BEST?
- A. Apply warm compresses to your breasts and take two aspirin as needed.
- B. Massage your breasts with lotion and wear loose-fitting clothing.
- C. Apply cold compresses to your breasts and wear a well-fitting, supportive bra.
- D. Take a diuretic once a day and avoid touching your breasts.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would increase circulation and increase discomfort, should avoid taking medications (2) not effective in decreasing discomfort (3) correct-during pregnancy there is an increase in lactiferous ducts and lobule-alveolar tissue (4) medications are to be avoided during pregnancy
An 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which of the following actions by the nurse is BEST?
- A. Observe the child at mealtime.
- B. Inquire about the child's eating patterns.
- C. Weigh the baby each month.
- D. Attempt to feed the baby for the mother.
Correct Answer: A
Rationale: Observing mealtime assesses feeding behaviors and parental interactions, identifying causes of poor weight gain. Options B, C, and D are less direct or premature.
A woman who recently had a simple mastectomy is about to be discharged. She seems very concerned about such things as where to find the best prosthesis, suitable underwear, and swimsuits, and adjusting to life with only one breast. Which resource is appropriate for the nurse to recommend?
- A. A psychologist or psychiatrist
- B. Reach to Recovery
- C. Pastoral counseling
- D. Her physician
Correct Answer: B
Rationale: Reach to Recovery offers peer support and resources for mastectomy patients, addressing prosthesis and lifestyle adjustments. Other options are less specific.
An 85-year-old client with diverticulitis has been vomiting and febrile for 12 hours. Where is the best location to assess skin turgor on this client?
- A. Dorsal hand
- B. Feet
- C. Back of the arm
- D. Sternum
Correct Answer: D
Rationale: This is the best area to check in the elderly due to loss of skin elasticity that occurs with aging. Answers A, B, and C are all influenced by loss of elasticity more than the sternum, so they are incorrect.
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