Nokea
The female client tells the clinic nurse she is going on a seven (7)-day cruise and is worried about getting motion sickness. Which information should the nurse discuss with the client?
- A. Make an appointment for the client to see the health-care provider.
- B. Recommend getting an over-the-counter scopolamine patch.
- C. Discourage the client from taking the trip because she is worried.
- D. Instruct the client to lie down and the motion sickness will go away.
Correct Answer: B
Rationale: A scopolamine patch prevents motion sickness effectively. HCP appointments, trip discouragement, and lying down are less practical.
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An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his temperature is slightly elevated. What does this suggest?
- A. Increased cerebral blood flow
- B. Respiratory depression
- C. Increased intracranial pressure
- D. Hyperoxygenation of the cerebrum
Correct Answer: C
Rationale: Increased systolic blood pressure, decreased pulse, and elevated temperature suggest increased intracranial pressure (Cushing's triad) post-head injury.
The client is scheduled for ear surgery. Which statement indicates the client needs more preoperative teaching concerning the surgery?
- A. If I have to sneeze or blow my nose, I will do it with my mouth open.
- B. I may get dizzy after the surgery, so I must be careful when walking.
- C. I will probably have some hearing loss after surgery, but hearing will return.
- D. I can shampoo my hair the day after surgery as long as I am careful.
Correct Answer: D
Rationale: Shampooing the day after ear surgery risks water entry and infection; typically, hair washing is delayed. Open-mouth sneezing, dizziness, and temporary hearing loss are correct.
The client has had an enucleation of the left eye. Which intervention should the nurse implement?
- A. Discuss the need for special eyeglasses.
- B. Refer the client for an ocular prosthesis.
- C. Help the client obtain a seeing-eye dog.
- D. Teach the client how to instill eyedrops.
Correct Answer: B
Rationale: An ocular prosthesis restores appearance post-enucleation, addressing psychosocial needs. Eyeglasses, guide dogs, and eyedrops are irrelevant post-enucleation.
Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs?
- A. Suggest installing multiple smoke alarms in the home.
- B. Recommend using a night-light in the hallway and bathroom.
- C. Discuss keeping a high-humidity atmosphere in the bedroom.
- D. Encourage the client to smell food prior to eating it.
Correct Answer: A
Rationale: Olfactory decline reduces smoke detection, making multiple smoke alarms critical for safety. Night-lights address vision, humidity is unrelated, and smelling food is unreliable.
Which assessment technique should the nurse use to assess the client's optic nerve?
- A. Have the client identify different smells.
- B. Have the client discriminate between sugar and salt.
- C. Have the client read the Snellen chart.
- D. Have the client say 'ah' to assess the rise of the uvula.
Correct Answer: C
Rationale: The optic nerve (cranial nerve II) is assessed by visual acuity tests like the Snellen chart. Smells (olfactory), taste (facial/glossopharyngeal), and uvula movement (vagus) involve other nerves.