Nokea
The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, 'I guess I can anticipate getting this disease myself at some point.' What is an appropriate response by the nurse?
- A. Engaging in regular exercise decreases the risk of AD.
- B. Having a family history of AD is not a risk factor.
- C. Try not to worry about this now as you can't do anything to prevent AD.
- D. You should avoid aluminum cans and cookware to prevent AD.
Correct Answer: A
Rationale: Regular exercise is associated with a reduced risk of Alzheimer disease. Family history is a risk factor, and aluminum is not a proven cause.
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Which of the following signs is highly suggestive of impaired hearing in an infant?
- A. The absence of the Moro reflex
- B. The absence of babbling by age 7 months
- C. A lack of eye contact when spoken to
- D. A lack of hand gesture to indicate wants
Correct Answer: B
Rationale: Absence of babbling by 7 months is a red flag for hearing impairment, as infants typically begin vocalizing in response to sounds. Other signs are less specific to hearing.
The nurse is assisting with the care of a client who is scheduled to receive an oxytocin infusion to induce labor. The nurse should recognize that oxytocin infusion can lead to
- A. decreased risk for postpartum hemorrhage
- B. fetal distress and cesarean birth
- C. increased risk for placenta previa
- D. preeclampsia and hypernatremia
Correct Answer: B
Rationale: Oxytocin can cause uterine hyperstimulation, leading to fetal distress and potential cesarean delivery.
The doctor has ordered 1 mg of Stadol (butorphanol) to be given IM. The medication is available in 4 mg per mL. The nurse should administer:
- A. 0.5 mL
- B. 0.25 mL
- C. 0.75 mL
- D. 1.0 mL
Correct Answer: B
Rationale: Calculate: 1 mg ÷ 4 mg/mL = 0.25 mL. This ensures the correct dose of Stadol is administered.
The nurse is discussing prostatectomies with a group of men. One man asks which kind of prostatectomy is done for someone who has benign prostatic hyperplasia (BPH). What answer should the nurse give?
- A. Transurethral resection prostatectomy
- B. Suprapubic prostatectomy
- C. Retropubic prostatectomy
- D. Perineal prostatectomy
Correct Answer: A
Rationale: Transurethral resection prostatectomy (TURP) is the most common procedure for BPH, removing prostate tissue via the urethra, minimally invasive compared to open approaches.
The nurse is talking with the parent of a pediatric client with type 1 diabetes mellitus who has influenza. Which of the following statements by the parent would require follow-up?
- A. I should encourage my child to drink more fluids.
- B. I will check my child's capillary blood glucose level more frequently.
- C. I should regularly check my child's urine for ketones.
- D. I will decrease my child's prescribed dose of insulin if my child is unable to eat.
Correct Answer: D
Rationale: Decreasing insulin during illness can lead to hyperglycemia or ketoacidosis, as insulin needs may increase.