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During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the well in the wheelchair. What is the priority nursing action?
- A. Ask the client to explain the bruises on the torso
- B. Assess the client's general hygiene and nutritional status
- C. Report the bruises to the client's health care provider (HCP)
- D. Talk to the client's child about the injuries
Correct Answer: C
Rationale: Multiple bruises in various stages raise suspicion for elder abuse, requiring reporting to the HCP for investigation. Further questioning may cause distress, and hygiene/nutrition assessments are secondary. Discussing with family risks alerting potential abusers.
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The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.
- A. I need to avoid taking medicines like ibuprofen without a prescription.
- B. I should avoid drinking excess coffee or cola.
- C. I should enroll in a smoking cessation program.
- D. I should reduce or eliminate my intake of alcoholic beverages.
- E. I will eliminate whole wheat foods, like breads and cereals, from my diet.
Correct Answer: A,B,C,D
Rationale: Avoiding NSAIDs (ibuprofen), excess coffee/cola, smoking, and alcohol reduces ulcer irritation and promotes healing. Whole wheat foods are beneficial for digestion and not contraindicated.
The nurse is talking with the parent of a pediatric client with attention deficit hyperactivity disorder who has a new prescription for methylphenidate. The parent asks, 'How will I know that the medication is effective?' Which of the following responses would be appropriate for the nurse to make?
- A. Your child will be less irritable.
- B. Your child will sleep longer at night.
- C. Your child will experience an increased appetite.
- D. Your child will complete tasks more easily and efficiently.
Correct Answer: D
Rationale: Methylphenidate improves focus and task completion in ADHD. It may increase irritability or decrease appetite as side effects, and sleep patterns vary but aren't a primary indicator of effectiveness.
The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply.
- A. Alanine aminotransferase from 20 U/L (0.33 ukat/L) to 80 U/L (1.34 ukat/L)
- B. High-density lipoprotein cholesterol from 48 mg/dL (1.24 mmol/L) to 30 mg/dL (0.78 mmol/L)
- C. Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L)
- D. Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L)
- E. Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L)
Correct Answer: C,D,E
Rationale: Rosuvastatin, a statin, is expected to lower LDL cholesterol, total cholesterol, and triglycerides, indicating therapeutic response. An increase in alanine aminotransferase suggests liver stress, which is a side effect to monitor, not a therapeutic goal. A decrease in HDL cholesterol is undesirable, as statins typically maintain or increase HDL.
The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the clients Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially?
- A. Immediately lower the bag and speak privately to unlicensed assistive personnel (UAP)
- B. Let UAP complete assigned tasks and speak to them at the end of the shift
- C. Praise UAP for encouraging the client to walk the entire hallway
- D. Speak with the nurse manager about the need for UAP inservice education
Correct Answer: A
Rationale: The Foley bag must be kept below bladder level to prevent urine backflow and infection risk. Immediate correction and private education ensure safety and learning without delay.
A client with tuberculosis has an order for Rifadin (rifampin). What vitamin is usually given with rifampin?
- A. Thiamine
- B. Pyridoxine
- C. Folic acid
- D. Cyanocobalamin
Correct Answer: B
Rationale: Pyridoxine (vitamin B6) is given with rifampin to prevent peripheral neuropathy, a side effect. Other vitamins are not typically associated with rifampin therapy.