Nokea
Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection?
- A. Close the day care center for 1 week to control the outbreak.
- B. Restrict the infected children from returning for 48 hours after treatment.
- C. Perform thorough hand washing before and after touching any child in the day care center.
- D. Set up a conference with the parents of each child to explain the situation carefully.
Correct Answer: C
Rationale: Thorough hand washing is the most effective measure to prevent the spread of bacterial conjunctivitis.
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The nurse is evaluating a weight-reduction plan designed for an obese client. Which statement by the client indicates the need for further teaching?
- A. It is so difficult to find food exchanges that taste good and fill me up.
- B. This diet doesn't let me go out for lunch with my friends at work anymore.
- C. I wish my mother could have seen me lose the 60 pounds in the last 9 months.
- D. My wife was kidding me the other night about my being a whole new husband.
Correct Answer: B
Rationale: Option 2 indicates that the client may be having difficulty in making appropriate dietary choices when going out for lunch or that he may perceive that his coworkers are uncomfortable with his need to eat differently. A sense of not fitting in can leave the obese individual isolated and therefore make it more difficult for him to maintain his diet at work. In the absence of other data, option 1 is a normal response to the changes in eating habits. Options 3 and 4 are responses indicating a positive perception of self; that is, another person has recognized these changes, and the client wishes to have been able to share these changes with his mother.
A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. Which of the following would be the nurse's best response?
- A. I know how you feel, but the medication will make your child feel better.'
- B. I can't let you do this without calling your physician first.'
- C. Can you tell me why you want to take your child home now?'
- D. I can imagine how hard this is for you, but it's not what's best for the child.'
Correct Answer: C
Rationale: Asking the mother to explain her reasons encourages open communication and helps the nurse understand her concerns, facilitating appropriate support or intervention.
The home care nurse notes that an older client is prescribed cimetidine. On assessment of the client, the nurse should check for which side effect of this medication?
- A. Fatigue
- B. Confusion
- C. Constipation
- D. Blurred vision
Correct Answer: B
Rationale: Cimetidine is a gastric acid secretion inhibitor. Older clients are especially susceptible to the central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, agitation, and hallucinations. None of the remaining options are associated with the use of this medication.
A 10-year-old child has the following blood glucose readings during a 24-hour period. Which reading requires the most immediate intervention?
- A. 50 mg/dL.
- B. 100 mg/dL.
- C. 150 mg/dL.
- D. 200 mg/dL.
Correct Answer: A
Rationale: A blood glucose of 50 mg/dL indicates hypoglycemia, requiring immediate intervention to prevent neurological complications.
You are caring for a client who has just had a thoracentesis. Which complication should you be aware of during the immediate post-operative period of time?
- A. Infection
- B. Pneumothorax
- C. Aspiration
- D. Dyspnea
Correct Answer: B
Rationale: Pneumothorax is a potential complication of thoracentesis due to the risk of lung puncture during the procedure, requiring immediate monitoring.