Nokea
The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant notification of the supervising registered nurse?
- A. I am going for repeat testing to confirm glaucoma.
- B. I am not able to exercise as much as I used to.
- C. I started taking esomeprazole for heartburn.
- D. My bowel movements are not regular.
Correct Answer: A
Rationale: Benztropine can increase intraocular pressure, worsening glaucoma, and requires immediate follow-up.
You may also like to solve these questions
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.
Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?
- A. Assist with plans for any clients discharged
- B. Provide basic hygiene care to all clients on the unit
- C. Assess a client after an acute myocardial infarction
- D. Gather the vital signs of all clients on the unit
Correct Answer: B
Rationale: Basic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs can be done by the RN and PN as they make rounds since this data is more critical to making decisions about the care of the clients.
A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction?
- A. I should leave the harness on during diaper changes.
- B. I will adjust the harness straps every 3-5 days.
- C. I will inspect the skin under the straps 2-3 times daily.
- D. The harness should keep my baby's legs bent and spread apart.
Correct Answer: B
Rationale: The harness straps should only be adjusted by a healthcare provider to ensure proper fit and treatment efficacy. Other statements reflect correct understanding of harness care.
The nurse is talking about diaper changes with a client who is 48 hours postpartum. The client states, 'I cannot change my baby's diaper as well as you can. Will you change it for me?' Which of the following responses would be appropriate for the nurse to make?
- A. Changing your baby's diaper now is important for the bonding process.
- B. I will stay at your bedside and watch while you change your baby's diaper.
- C. It is more important for you to take care of yourself now, so I will change your baby's diaper.
- D. It is time that you change your baby's diaper because you will have to do it by yourself after discharge.
Correct Answer: B
Rationale: Supporting the client while they change the diaper builds confidence and promotes independence.
The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply.
- A. I can mix the medication in a bowl of my child's favorite cereal.
- B. I should give another dose if my child vomits after taking the medication.
- C. I should measure liquid medications using an oral syringe.
- D. I will encourage my child to help me as I prepare the medication.
- E. I will place my child in time-out if the medication is refused.
Correct Answer: C
Rationale: Using an oral syringe ensures accurate dosing. Mixing with food, redosing after vomiting, involving the child in preparation, or punishing refusal are inappropriate.