Nokea
Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, 'When I have difficulty breathing at night, I will...'
- A. Lie on my back with head & shoulders elevated on a pillow
- B. Lie flat on my stomach with head to one side
- C. Sit on side of my bed & rest my arms over pillows on top of my raised bedside table
- D. Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me
Correct Answer: C
Rationale: The correct answer is C: Sit on side of my bed & rest my arms over pillows on top of my raised bedside table. Orthopneic position is sitting upright with arms supported, which helps improve lung expansion and ease breathing. Choice A is incorrect as lying on the back can worsen breathing difficulties. Choice B is incorrect as lying flat on the stomach hinders breathing. Choice D is incorrect as lying on the side does not provide the same lung expansion as sitting upright.
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Nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. Which should the nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The presentation of linear clusters of fluid-containing vesicles with crusting is characteristic of herpes zoster, also known as shingles. This is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution along a dermatome is a key feature distinguishing it from other conditions. Allergic reaction (A) typically presents with hives or erythema, not vesicles. Ringworm (B) presents with a circular, scaly rash. Systemic lupus erythematosus (C) is an autoimmune disease with a different presentation.
Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion?
- A. "rotavirus"
- B. varicella
- C. herpes zoster
- D. HPV
- E. seasonal influenza
Correct Answer: B, D, E
Rationale: The correct answers are B (varicella), D (HPV), and E (seasonal influenza) because these are recommended immunizations for adolescents by the CDC. Varicella vaccine protects against chickenpox, HPV vaccine prevents certain types of cancers, and seasonal influenza vaccine helps prevent the flu. Rotavirus (A) is typically given to infants, not adolescents. Herpes zoster (C) is recommended for older adults, not adolescents.
A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. At age 2, children often exhibit behaviors to assert their independence. By saying 'no' and resisting help with dressing, the toddler is showing a desire to do things on her own and asserting her autonomy. This behavior aligns with the typical developmental stage of toddlers seeking independence and autonomy. Choices B, C, and D are incorrect because they do not align with the typical behaviors and developmental milestones of a 2-year-old. Choice B (Developing sense of trust) is more characteristic of infancy, choice C (Manifesting anger management problem) is not appropriate for a toddler's behavior in this context, and choice D (Attempting to finish a project she started) does not reflect the developmental stage of a 2-year-old.
A home health nurse is discussing dangers of carbon monoxide poisoning with client. Which of following info should nurse include in her counseling?
- A. Carbon monoxide has distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with Hgb in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with Hgb in the body. Carbon monoxide is a colorless and odorless gas, so it does not have a distinct odor (choice A). Water heaters should be inspected annually, not every 5 years (choice B). Carbon monoxide poisoning affects the blood's ability to carry oxygen, not the lungs directly (choice C). By binding with hemoglobin, carbon monoxide reduces the blood's oxygen-carrying capacity, leading to tissue hypoxia and potentially fatal consequences. Therefore, it is crucial for the nurse to emphasize this information during counseling to help the client understand the serious implications of carbon monoxide exposure.
Nurse performing an admission assessment for an older adult client. After gathering assessment data & performing a review of systems, which of the following actions is the priority for nursing?
- A. Orient client to his room
- B. Conduct client care conference
- C. Review client's medical orders
- D. Develop plan of care
Correct Answer: A
Rationale: The correct answer is A: Orient client to his room. This is the priority because it ensures the client's safety and comfort by helping them become familiar with their surroundings. Orienting the client first establishes a foundation for effective care delivery. Conducting a client care conference (choice B) can come later once the client is settled. Reviewing medical orders (choice C) is important but can be done after the client is oriented. Developing a plan of care (choice D) is essential but should be based on a thorough assessment, including orienting the client.