Nokea
Damage to the VIII cranial nerve results in:
- A. Air conduction loss
- B. Sensorineural loss
- C. Mixed hearing disorders
- D. Tinnitus
Correct Answer: B
Rationale: The VIII cranial nerve (vestibulocochlear) is responsible for hearing and balance; damage causes sensorineural hearing loss, affecting the inner ear or nerve pathways.
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The nurse is teaching the parent of a 7-year-old client with celiac disease. Which statement by the parent would require follow-up?
- A. My child can consume small amounts of barley
- B. My child is allowed to eat rice, corn, and potatoes
- C. My child needs to be on a gluten-free diet for life
- D. My child should avoid eating processed foods
Correct Answer: A
Rationale: Barley contains gluten, which is harmful in celiac disease, indicating a need for further teaching. Rice, corn, potatoes, lifelong gluten-free diet, and avoiding processed foods are correct.
Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0
The nurse recognizes which of the following factors as possibly contributing to a sentinel event?
- A. Administered warfarin to a client with an INR of 6.0
- B. Administered flumazenil to a client who overdosed on lorazepam
- C. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
- D. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
Correct Answer: A
Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.
The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
- A. Widening pulse pressure
- B. Pleural friction rub
- C. Distended neck veins
- D. Bradycardia
Correct Answer: C
Rationale: Distended neck veins. Cardiac tamponade causes venous congestion, leading to distended neck veins.
A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
- A. Why don't we now have the client turn back to the left side.
- B. That was done correctly. Did you have any problems with the insertion?
- C. Let's check to see if the suppository is in far enough.
- D. Did you feel any stool in the intestinal tract?
Correct Answer: B
Rationale: Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication.
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
- A. Maintain good nutrition
- B. Stay in school
- C. Keep in contact with the child's father
- D. Get adequate sleep
Correct Answer: A
Rationale: Maintain good nutrition. Adequate nutrition, especially protein, vitamins, and iron, is critical for healthy fetal development and reducing low-birth-weight risks.