Nokea
A teenager comes to the clinic complaining of fatigue, a sore throat, and flu-like symptoms for the previous two weeks. Physical exam reveals enlarged lymph nodes and temperature of 100.3°F (37.9°C). Which of the following statements by the nurse is BEST?
- A. Cover your mouth and nose when you sneeze or cough.
- B. Eat in a separate room away from your family.
- C. Don't share your drinking glass or silverware with anybody.
- D. Stay in your room until all of your symptoms are gone.
Correct Answer: C
Rationale: symptoms indicate mononucleosis, spread by direct contact; advise family to avoid contact with cups and silverware for about 3 months
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A client who has been abusing alcohol and other drugs for six years. The nursing diagnosis is ineffective individual coping.
Which of the following nursing actions should take priority during the working stage of their relationship?
- A. Observe the client every half-hour to determine the extent of drug-seeking behavior.
- B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.
- C. Help the client obtain a sponsor through a 12-step group in the client's local area.
- D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems
A group of senior citizens.
The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the nurse emphasize to facilitate regular bowel elimination?
- A. Avoid strenuous activity.
- B. Eat more foods with increased bulk.
- C. Decrease fluid intake to decrease urinary losses.
- D. Use oral laxatives so that a bowel pattern emerges.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) regular exercise program facilitates bowel elimination (2) correct-contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis (3) normal fluid intake of 1,500 cc/day facilitates bowel elimination (4) laxatives used as last resort because they become habit-forming
The nurse is caring for a toddler in traction, and the toddler is receiving chloral hydrate (Noctec). The toddler becomes irritable and extremely restless. Which nursing action is MOST appropriate?
- A. Give the next dose of chloral hydrate early.
- B. Contact the physician to obtain new orders.
- C. Instruct the toddler's mother to read to him.
- D. Take the toddler out of traction for 30 minutes.
Correct Answer: B
Rationale: Irritability and restlessness suggest a paradoxical reaction to chloral hydrate, requiring physician notification for medication adjustment. Options A, C, and D are unsafe or ineffective.
The nurse is caring for a client who is receiving a continuous IV infusion of dopamine for hypotension. Which of the following findings should the nurse report immediately?
- A. Heart rate of 100 bpm.
- B. Blood pressure of 90/60 mmHg.
- C. Urine output of 20 mL/hour.
- D. Respiratory rate of 18 breaths/min.
Correct Answer: C
Rationale: Urine output of 20 mL/hour indicates oliguria, suggesting inadequate perfusion despite dopamine. Options A, B, and D are expected.
A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?
- A. Lemonade.
- B. Prune juice.
- C. Milk.
- D. Orange juice.
Correct Answer: B
Rationale: promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon