Nokea
The client is two(2) hours postoperative right ear mastoidectomy. Which assessment data should be reported to the health-care provider?
- A. Complaints of aural fullness.
- B. Hearing loss in the affected ear.
- C. No vertigo.
- D. Facial drooping.
Correct Answer: D
Rationale: Facial drooping indicates potential facial nerve involvement requiring immediate attention.
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Which risk factor should the nurse expect to find in the client diagnosed with pancreatic cancer?
- A. Chewing tobacco
- B. Low-fat diet
- C. Chronic alcoholism
- D. Exposure to industrial chemicals
Correct Answer: C
Rationale: Chronic alcoholism is a well-established risk factor for pancreatic cancer.
The client suspected of having Stage I of Lyme disease is seen in the health care clinic and is told that the Lyme disease test is positive. The client asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating which of the following to be part of the treatment plan?
- A. no treatment unless symptoms develop
- B. a 3-week course of oral antibiotic therapy
- C. treatment with intravenous penicillin G
- D. ultraviolet light therapy
Correct Answer: B
Rationale: Stage I Lyme disease is treated with a 2-4 week course of oral antibiotics (e.g., doxycycline) to eradicate the infection.
The nurse is caring for a male client diagnosed with folliculitis barbae. Which information should the nurse teach to prevent a reoccurrence?
- A. Tell the client to not shave the face.
- B. Instruct the client to rub on astringent aftershave lotion.
- C. Recommend the client apply hot packs for 20 minutes before shaving.
- D. Teach the client to use an antibacterial soap on the face.
Correct Answer: C
Rationale: Hot packs soften the skin and hair, reducing irritation and bacterial entry during shaving.
Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain?
- A. Ineffective coping.
- B. Potential for injury.
- C. Alteration in comfort.
- D. Altered sensory input.
Correct Answer: C
Rationale: Alteration in comfort directly reflects the client's experience of acute pain, aligning with nursing diagnoses focused on the primary issue.
Which instructions would be appropriate for the nurse to give to a client with acute conjunctivitis from Staphylococcus?
- A. Wash your hands before cleansing the eye and giving eyedrops, soak lids with warm saline, and do not share towels, make-up, or contact lenses.
- B. You can rub your eyes with a clean, soft cloth for itching.
- C. All of the above
- D. None of the above
Correct Answer: A
Rationale: Handwashing prevents cross-contamination, soaking lids softens crusts, and not sharing items reduces spread. Rubbing eyes can worsen the condition and spread infection.