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During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond?
- A. Ask for a demonstration of these exercises
- B. Explain that coughing should be avoided
- C. Review the client’s previous surgical history
- D. Document the client's understanding of teaching
Correct Answer: A
Rationale: Asking for a demonstration ensures that the client understands the proper technique for coughing and deep breathing exercises.
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A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to 'freeze' and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond?
- A. Re-orient the client to his present location and circumstances
- B. Confirm that this is an effective technique to help with ambulation
- C. Assist the client to a carpeted area where he can walk more easily
- D. Plan to assess the client's cognition after returning to his room
Correct Answer: B
Rationale: Pretending to step over a crack is a known technique that can help clients with PD overcome freezing episodes.
Which statement by the mother of a child with rheumatic fever (RF) indicates that she has an understanding of prevention for her other children?
- A. “Whenever one of them gets a sore throat, I will give that child an antibiotic.â€
- B. “There is no treatment since it is viral and must run its course.â€
- C. “If their culture is positive for group A streptococcus, I will give them a full course of their antibiotic.â€
- D. “If their culture is positive for staphylococcus A, I will give them a full course of their antibiotic.â€
Correct Answer: C
Rationale: A positive culture for group A streptococcus indicates a bacterial infection that requires a full course of antibiotics to prevent rheumatic fever, which can develop as a complication of untreated strep throat.
A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?
- A. Tell the client to remain in bed
- B. Apply warm compresses to the affected leg.
- C. Administer pain medication as prescribed.
- D. Encourage the client to elevate the affected leg.
Correct Answer: A
Rationale: The symptoms suggest deep vein thrombosis (DVT). Bed rest prevents dislodgment of the clot, reducing the risk of pulmonary embolism.
A psychiatric referral is warranted in a preschool child with the following:
- A. Night terrors
- B. Separation anxiety
- C. Scared of ghosts
- D. Masturbation
Correct Answer: B
Rationale: Separation anxiety in a preschool child, especially if it is severe and persistent, may warrant a psychiatric referral to assess for anxiety disorders.
A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider?
- A. Weakness and fatigue
- B. Intestinal cramping
- C. Weight loss
- D. Jaundiced sclera
Correct Answer: D
Rationale: Jaundiced sclera indicates possible liver involvement, which could be due to a tropical disease such as hepatitis or leptospirosis.