Nokea
A usually reliable interpreter called by the nurse to help communicate with a mother of a child who does not speak English and has brought her child in for a routine visit has yet to arrive in the clinic. The nurse has paged the interpreter several times. Which of the following should the nurse do next?
- A. Continue with the examination.
- B. Reschedule the infant's appointment for later in the week.
- C. Ask the mother to stay longer in the hope that the interpreter arrives.
- D. Page the interpreter one more time.
Correct Answer: B
Rationale: Rescheduling ensures effective communication with the interpreter, avoiding potential misunderstandings during the visit.
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A client is taking 600 mg of valproic acid (Depakene) twice daily. The nurse should assess the client for which of the following? Select all that apply.
- A. Tremors.
- B. Hair loss.
- C. Gastrointestinal upset.
- D. Anorexia.
- E. Weight gain.
Correct Answer: A,C,E
Rationale: Valproic acid commonly causes tremors, gastrointestinal upset (e.g., nausea), and weight gain. Hair loss and anorexia are less common side effects.
While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal delivery, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the physician because these findings indicate which of the following?
- A. Biliary atresia.
- B. Rh isoimmunization.
- C. ABO incompatibility.
- D. Esophageal varices.
Correct Answer: A
Rationale: Pale stools and jaundice in a neonate suggest biliary atresia, a condition requiring urgent evaluation.
The nurse is teaching an unlicensed assistive personnel about the care of clients with self-mutilation. Which of the following, if stated by the unlicensed personnel about self-mutilation, demonstrates that the teaching has been effective?
- A. It is a means of getting what the person wants.'
- B. It is a nonserious event that can be ignored.'
- C. It is a way to express anger and rage.'
- D. It is a form of manipulation.'
Correct Answer: C
Rationale: Self-mutilation is often a way to express intense emotions like anger or rage, indicating the assistant understands its emotional significance.
The nurse is teaching a client with a new diagnosis of gout about medication management. Which of the following medications should the client expect to take during an acute attack?
- A. Colchicine.
- B. Allopurinol.
- C. Probenecid.
- D. Methotrexate.
Correct Answer: A
Rationale: Colchicine is used to relieve inflammation during an acute gout attack.
Which interventions should the nurse include in the plan of care for a client who is scheduled for a bronchoscopy? Select all that apply.
- A. Remove any dentures.
- B. Remove contact lenses.
- C. Provide access to limited food and drink.
- D. Ensure that the informed consent is signed.
- E. Have the client void before transport to endoscopy.
Correct Answer: A,B,D,E
Rationale: If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to him or her. The client must sign an informed consent because the procedure is invasive. For comfort reasons, the client also should be asked about the need to void before transport to the endoscopy department. The client is not allowed to eat or drink usually for 6 to 8 hours (or as specified by the primary health care provider) before the procedure to prevent the risk of aspiration.