Nokea
An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?
- A. It should take about 6-8 weeks before your symptoms improve
- B. Tell me what you had to eat yesterday
- C. We will refer you to the dietitian
- D. You must not be following your diet
Correct Answer: B
Rationale: Asking about recent food intake helps identify unintentional gluten exposure, common in new celiac diagnoses. Assuming 6-8 weeks, immediate referral, or blaming non-compliance may overlook dietary errors or other causes.
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The nurse observes a client self-administering nasal fluticasone. Which observation would require the practical nurse to intervene and reinforce the instructions provided by the registered nurse?
- A. A sitting position is assumed as the head is bowed slightly forward
- B. The client points the spray tip toward the nasal septum during instillation
- C. The nasal spray tip is inserted into the nostril as the other nostril is occluded
- D. While administering the medication, the client inhales deeply through the nose
Correct Answer: B
Rationale: Pointing fluticasone toward the nasal septum risks irritation or bleeding; it should be aimed laterally. Sitting with head forward, occluding the other nostril, and inhaling deeply are correct administration techniques.
A patient has been ordered to get Tegretol for the first time. Which of the following side effects is not associated with Tegretol?
- A. Sore throat
- B. Vertigo
- C. Fever
- D. Shortness of breath
Correct Answer: D
Rationale: A-C are associated side effects of Tegretol.
The nurse in the pediatric unit is collecting data from several newly admitted clients. Which finding should the nurse follow up for possible abuse and mandatory reporting?
- A. A 2-month-old who rolled off the changing table and is now lethargic
- B. A 3-month-old with flat bluish discoloration on the buttock that the mother says has been present since birth
- C. A 3-year-old with forehead bruises that the mother says resulted from running into a table
- D. A 4-year-old who pulled boiling water off the stove and has splatter burns on the arms
Correct Answer: A
Rationale: A 2-month-old cannot roll, and lethargy after a fall suggests possible non-accidental head trauma, requiring abuse investigation. Bluish buttock marks may be Mongolian spots (benign), and splatter burns are consistent with an accident.
A primigravida arrives at the labor unit stating that she is having contractions. Which statement describes the presence of true contractions?
- A. True contractions begin in the lower abdomen.
- B. True contractions have a consistent frequency.
- C. True contractions lessen with physical activity.
- D. True contractions are inconsistent in frequency.
Correct Answer: B
Rationale: True contractions have a consistent frequency , becoming regular and stronger. They start in the back or upper abdomen (A is incorrect), intensify with activity (C is incorrect), and are regular (D is incorrect).
Which of the following activities demonstrate safe client handling practices? Select all that apply.
- A. 1 person assisting a client who is 8 hours post hip replacement surgery with a position change
- B. 1 person using a gait belt while transferring a partial weight-bearing client from the bed to a chair
- C. 2 people repositioning a client who is comatose and has been on the left side for 2 hours
- D. 3 people pulling up in bed a client who weighs 331 lb (150 kg)
Correct Answer: B,C,D
Rationale: Using a gait belt, two people for a comatose client, and three for a heavy client ensure safety and prevent injury. One person for a recent hip replacement risks falls or dislocation due to limited mobility.