Nokea
In addition to standard precautions, a nurse should implement contact precautions for which client?
- A. 60 year-old with herpes simplex
- B. 6 year-old with mononucleosis
- C. 45 year-old with pneumonia
- D. 3 year-old with scarlet fever
Correct Answer: A
Rationale: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.
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The physician has prescribed hydralazine (Apresoline) for a client with acute glomerulonephritis. Which finding indicates that the drug is having the desired effect?
- A. The client's appetite has improved.
- B. Creatinine levels have returned to normal.
- C. The client's blood pressure has decreased.
- D. Urinary output is amber in color.
Correct Answer: C
Rationale: Apresoline (hydralazine) is an antihypertensive; therefore, a decrease in blood pressure indicates the medication is working. Answers A, B, and D indicate that the overall condition of the client is improving, but they are not the result of the medication.
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room.
- A. Which assessment finding three hours after admission should be reported to the physician for a five-year-old with a closed head injury?
- B. The client has slight edema of the eyelids.
- C. There is clear fluid draining from the client’s right ear.
- D. There is some bleeding from the child’s lacerations.
- E. The client withdraws in response to painful stimuli.
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage due to a meningeal rupture, a serious complication that risks meningitis and requires immediate reporting. Eyelid edema, minor bleeding, and withdrawal to pain are less urgent or expected findings.
The nurse is caring for a client with a history of heart failure who is receiving metoprolol (Lopressor) 50 mg PO bid. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 50 bpm.
- B. Blood pressure of 130/80 mmHg.
- C. Respiratory rate of 18 breaths/min.
- D. Oxygen saturation of 95%.
Correct Answer: A
Rationale: A heart rate of 50 bpm indicates bradycardia, a serious side effect of metoprolol, a beta-blocker, requiring immediate evaluation to prevent reduced cardiac output. Options B, C, and D are normal: blood pressure 130/80 mmHg, respiratory rate 18 breaths/min, and oxygen saturation 95% are stable.
A 25-year-old man is in an acute manic episode. The nurse knows that which client behavior would be MOST characteristic of mania?
- A. Agitation, grandiose delusions, euphoria, difficulty concentrating.
- B. Difficulty in decision-making, preoccupation with self, distorted perceptions.
- C. Paranoia, hallucinations, disturbed thought processes, hypervigilance.
- D. Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.
Correct Answer: A
Rationale: characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems; mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior
The nurse is planning care for an adult who has myasthenia gravis. What should be included in the care plan?
- A. Plan to have the client bathe in the evening.
- B. Check the client's gag and swallowing reflexes before the client eats.
- C. Encourage frequent bathing.
- D. Encourage the client to be most active in the middle of the day.
Correct Answer: B
Rationale: Myasthenia gravis causes muscle weakness, risking aspiration; checking gag and swallowing reflexes before eating ensures safety, unlike bathing or activity timing.