Nokea
Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify that the client: Select all that apply.
- A. Is older than 65 years.
- B. Has had symptoms of the stroke less than 3 years.
- C. Has a blood pressure within normal limits.
- D. Does not have active internal bleeding.
- E. Has not had an alcoholic beverage within the last 8 hours.
Correct Answer: C, D
Rationale: t-PA requires normal blood pressure and no active bleeding to minimize complications like hemorrhage.
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To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?
- A. Bathe daily.
- B. Eat a high-carbohydrate diet.
- C. Shift your weight every 15 minutes.
- D. Move from the bed to the wheelchair every 2 hours.
Correct Answer: C
Rationale: Shifting weight every 15 minutes relieves pressure on bony prominences, reducing pressure ulcer risk. The other options are less directly related to prevention.
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse should expect to observe which of the following symptoms?
- A. Positive Babinski reflex.
- B. High-pitched cry.
- C. Hypothermia.
- D. Kernig's sign.
Correct Answer: B
Rationale: A high-pitched cry is a common symptom of bacterial meningitis in infants, indicating neurological irritation.
A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?
- A. What do you think about having your mother leave the room?'
- B. Mother, do you think your daughter is sexually active?'
- C. Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter.'
- D. The two of you seem like you share everything. I am going to ask questions about sexual history now.'
Correct Answer: C
Rationale: Requesting the mother to leave ensures privacy for the teen, promoting honest responses during the sexual history.
A client with a history of gastroesophageal reflux disease (GERD) is admitted with chest pain. The nurse should prioritize which of the following interventions?
- A. Obtain a 12-lead ECG.
- B. Administer omeprazole.
- C. Position the client supine.
- D. Administer an antacid.
Correct Answer: A
Rationale: Chest pain in GERD may mimic cardiac pain, so obtaining a 12-lead ECG rules out myocardial infarction.
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.