Nokea
An 80-year-old client is prescribed codeine for a severe cough. The home health nurse is reinforcing instructions on how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply.
- A. I'll be sure to apply sunscreen if I go outside.
- B. I'll drink at least 8 glasses of water a day.
- C. I'll drink decaffeinated coffee so I can sleep at night.
- D. I'll sit on the side of my bed for a few minutes before getting up.
- E. I'll take my medicine with food.
Correct Answer: B,D,E
Rationale: Drinking water (B) prevents constipation, sitting before standing (D) avoids orthostatic hypotension, and taking with food (E) reduces nausea. Sunscreen (A) and decaf coffee (C) are unrelated to codeine effects.
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The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?
- A. Ask the interpreter to explain the discussion
- B. Confirm the client's consent with the interpreter, using gestures
- C. Have the interpreter witness the signature
- D. Indicate that the interpreter was used when witnessing the client's signature
Correct Answer: A
Rationale: Asking the interpreter to explain the discussion (A) ensures the nurse understands any concerns or clarifications, verifying informed consent. Gestures (B) are unreliable, the interpreter witnessing (C) is inappropriate, and noting interpreter use (D) is insufficient without understanding the discussion.
The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
- A. Stressors in the home
- B. Medication compliance
- C. Exposure to hot temperatures
- D. Alcohol use
Correct Answer: B
Rationale: Medication compliance. Ensuring adherence to fluphenazine is critical for symptom management in schizophrenia.
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
- A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
- B. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.
- C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
- D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
Correct Answer: A
Rationale: To elicit the biceps reflex, the nurse places her thumb on the biceps tendon in the antecubital space and taps it with a reflex hammer, so A is correct. Answer B is incorrect as it describes a different technique. Answer C refers to the patellar reflex, and Answer D is not a standard method for the biceps reflex.
The nurse is reinforcing teaching to the parent of a child recently diagnosed with attention deficit hyperactivity disorder, combined type. Which statement by the parent requires intervention?
- A. I should offer only two options when my child is choosing things like clothes or meals.
- B. I will need to advocate for an individualized educational plan for my child.
- C. My child will most likely outgrow this disorder in early adulthood, around age 20.
- D. When talking with my child, I should focus and not be multi-tasking.
Correct Answer: C
Rationale: ADHD often persists into adulthood, so stating it will be outgrown by age 20 (C) is incorrect and requires intervention. Limiting choices (A), advocating for an IEP (B), and focusing during conversations (D) are appropriate.
The nurse is caring for a 10-year-old client with sickle cell disease who is experiencing an episode of acute pain. Which of the following diversional activities would be appropriate for the nurse to offer the client?
- A. putting together a puzzle in the activity room
- B. reading an age-appropriate book
- C. walking down the unit hallways
- D. playing with finger puppets
Correct Answer: B
Rationale: Reading a book (B) is a calm, stationary activity suitable for pain management. Puzzles (A) may require movement, walking (C) could worsen pain, and puppets (D) may be too childish for a 10-year-old.