Nokea
The home care nurse is evaluating a client's understanding of the self-management of trigeminal neuralgia. Which client statement indicates that there is a need for further teaching?
- A. I should chew on my good side.
- B. An analgesic will relieve my pain.
- C. I should use warm mouthwash for oral hygiene.
- D. Taking my carbamazepine will help control my pain.
Correct Answer: B
Rationale: Chronic irritation of cranial nerve V results in trigeminal neuralgia, and it is characterized by intermittent episodes of intense pain of sudden onset on the affected side of the face. The pain is rarely relieved by analgesics. It is recommended that clients chew on the unaffected side and use warm mouthwash for oral hygiene. Medications such as carbamazepine help control the pain of trigeminal neuralgia.
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The nurse teaches the mother of a newly circumcised infant about postcircumcision care. Which statement by the mother indicates an understanding of the care required?
- A. I need to clean the penis every hour with baby wipes.
- B. I need to check for bleeding every hour for the first 12 hours.
- C. My baby will not urinate for the next 24 hours because of swelling.
- D. I need to wrap the penis completely in dry sterile gauze, making sure that it is dry when I change his diaper.
Correct Answer: B
Rationale: After circumcision, the mother needs to be taught to observe for bleeding and assess the site hourly for 8 to 12 hours. Water is used for cleaning because soap or baby wipes may irritate the area and cause discomfort. Voiding needs to be assessed. The mother should call the primary health care provider if the baby has not urinated within 24 hours because swelling or damage may obstruct urine output. When the diaper is changed, Vaseline gauze should be reapplied (if prescribed). Frequent diaper changing prevents contamination of the site.
Which problems should the nurse counsel adoptive parents about encountering? Select all that apply.
- A. Setting unrealistically high standard for themselves
- B. Lacking basic knowledge about the child's biological health history
- C. Having difficulty assimilating if the child is adopted from another country
- D. Having difficulty deciding when and how to tell the child about being adopted
- E. Feeling the need for more assistance and support in child-rearing than biological parents do
- F. Dealing with feelings of loss and grief in the child regarding family social history and traditions
Correct Answer: A,B,C,D,F
Rationale: Adoptive parents may add pressure to themselves by setting unrealistically high standards for themselves. Additional problems adoptive families may face include possible lack of knowledge about the child's biological health history, difficulty assimilating if the child is adopted from another country, difficulty deciding when and how to tell the child about being adopted, and dealing with social and traditional issues of the biological family. Otherwise, most problems faced by adoptive parents are no different from those encountered by natural parents. All parents want to be good parents. Both adoptive parents and biological parents need information, support, and guidance to prepare them to care for their child.
The nurse is preparing to assess cranial nerve VIII on a client. Which tests will the nurse perform? Select all that apply.
- A. Allen's test
- B. Phalen's test
- C. the Rinne test
- D. the Weber test
Correct Answer: C,D
Rationale: Cranial nerve VIII (vestibulocochlear) is assessed with the Rinne and Weber tests for hearing. Allen's and Phalen's tests assess circulation and carpal tunnel, respectively.
A client who is taking tranylcypromine sulfate requests information about foods that are acceptable to eat while taking the medication. Which foods are safe to consume while taking this medication?
- A. Yogurt
- B. Raisins
- C. Oranges
- D. Smoked fish
Correct Answer: C
Rationale: Tranylcypromine sulfate is classified as a monoamine oxidase inhibitor (MAOI); as such, tyramine-containing food should be avoided. Oranges are permissible. Types of food to be avoided include—but are not limited to—yogurt, raisins, and smoked fish. Additionally, beer, wine, caffeinated beverages, pickled meats, yeast preparations, avocados, bananas, and plums are to be avoided.
A nurse working in the neonatal intensive care unit (NICU) teaches handwashing techniques to the parents of an infant who is receiving antibiotic treatment for a neonatal infection. The nurse determines that the parents understand the primary purpose of hand washing if which statement is made?
- A. It is primarily done to reduce their fears.
- B. It is primarily done to minimize the spread of infection to other siblings.
- C. It is primarily done to allow them an opportunity to communicate with each other and staff.
- D. It is primarily done to reduce the possibility of transmitting an environmental infection to the infant.
Correct Answer: D
Rationale: Appropriate hand washing by staff and parents has been effective for the prevention of nosocomial infections in nursery units. This action also promotes parents taking an active part in the care of their infant. Reducing fears and encouraging communication are not the primary reasons to perform hand washing. Because the infant already has an infection and is in the NICU, transference to siblings is not the best choice.