Nokea
An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation?
- A. Perform passive range-of-motion exercises before walking.
- B. Encourage partial weight bearing while ambulating.
- C. Immobilize the extremity between activities.
- D. Restrict the amount of time and the distance the man walks.
Correct Answer: B
Rationale: would relieve weight, pressure, and stress on affected leg, may use walker
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The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to:
- A. XII (hypoglossal)
- B. X (vagus)
- C. IX (glossopharyngeal)
- D. VII (facial)
Correct Answer: B
Rationale: The vagus nerve (X) innervates the pharynx and is responsible for the gag reflex, so its injury would cause an absent gag reflex.
Which of the following statements by a client with a seizure disorder who is taking topiramate (Topamax) indicates that the client has understood the nurse's instruction?
- A. I will take the medicine before going to bed.
- B. I will drink 8 to 10 ten-ounce glasses of water a day.
- C. I will eat plenty of fresh fruits.
- D. I must take the medicine with a meal or snack.
Correct Answer: B
Rationale: Topiramate increases the risk of kidney stones, so adequate hydration (8-10 glasses of water daily) is essential to prevent this complication.
The mother of a 24-month-old child tells the nurse that she is concerned that her child's language abilities are delayed. Which of the following language milestones does the nurse expect the child to exhibit?
- A. Understands 300 words and uses two- and three-word sentences.
- B. Says and understands a few words, such as 'Mama' and 'Dada,' and can imitate animal sounds, such as 'moo' and 'woof.'
- C. Says and understands four to six words but understands more and can point to items he wants.
- D. Says and understands up to 20 words and can point to his body parts.
Correct Answer: A
Rationale: A 24-month-old should understand about 300 words and use two- to three-word sentences (A). Other options (B, C, D) describe earlier developmental stages.
The nurse caring for a client with chest tubes notes that the Pleuravac's collection chambers are full. The nurse should:
- A. Add more water to the suction-control chamber
- B. Remove the drainage using a 60 mL syringe
- C. Milk the tubing to facilitate drainage
- D. Prepare a new unit for continuing collection
Correct Answer: D
Rationale: When the Pleuravac collection chambers are full, a new unit is needed to continue effective drainage and maintain the closed system.
The nurse is preparing a client with gastroesophageal reflux disease (GERD) for discharge. The nurse should tell the client to:
- A. Eat a small snack before bedtime
- B. Sleep on his right side
- C. Avoid carbonated beverages
- D. Increase his intake of citrus fruits
Correct Answer: C
Rationale: Carbonated beverages can increase stomach pressure and worsen GERD symptoms by promoting acid reflux.