Nokea
An adult is admitted with meningitis. During the acute phase of the illness, which measure should the nurse include in the nursing care plan to reduce the chance of seizures?
- A. Play the client's favorite music.
- B. Stimulate the client every two hours.
- C. Keep a padded tongue blade at the bedside.
- D. Darken the client's room.
Correct Answer: D
Rationale: Darkening the room minimizes sensory stimulation, reducing seizure risk in meningitis, where neurological irritability is common.
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The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?
- A. Low tar cigarettes are less harmful during pregnancy
- B. There is a relationship between smoking and low birth weight
- C. The placenta serves as a barrier to nicotine
- D. Moderate smoking is effective in weight control
Correct Answer: B
Rationale: There is a relationship between smoking and low birth weight. Smoking reduces placental blood flow, contributing to fetal hypoxia and low birth weight.
A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the 'evil eye.' The nurse should communicate to other personnel that the appropriate approach is to
- A. Touch the baby after looking at him
- B. Talk very slowly while speaking to him
- C. Avoid touching the child
- D. Look only at the parents
Correct Answer: A
Rationale: In many cultures, an 'evil eye' is cast when looking at a person without touching him. Thus, the spell is broken by touching while looking or assessing.
When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by
- A. Reduced oxygen capacity of cells due to lack of iron
- B. An imbalance between red cell destruction and production
- C. Depression of red and white cells and platelets
- D. Inability of sickle shaped cells to regenerate
Correct Answer: B
Rationale: An imbalance between red cell destruction and production. Anemia results when the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow (red cell life span shortened from 120 days to 12-20 days).
The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
- A. Repeatedly checking that the door is locked
- B. Verbalized suspicions about thefts
- C. Preference for consistent caregivers
- D. Repetitive, involuntary movements
Correct Answer: A
Rationale: Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors, performed to reduce feelings of anxiety, often interfere with normal function and employment.
The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
- A. instruct the client to breathe into a paper bag
- B. place the client in a high Fowler's position
- C. assist the client with pursed lip breathing
- D. administer oxygen at 6L/minute via nasal cannula
Correct Answer: C
Rationale: Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.