Nokea
The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed?
- A. I have been very careful to wash my hands after I go to the bathroom.
- B. I have had to take Tylenol several times this week for this sinus infection I have.
- C. I have been very careful not to handle my child's toys or eating utensils.
- D. My husband has been preparing all of the meals since I've been sick.
Correct Answer: B
Rationale: Tylenol (acetaminophen) is hepatotoxic and should be avoided in hepatitis A, which impairs liver function, indicating a need for further teaching. Options A, C, and D show correct precautions to prevent oral-fecal transmission.
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The nurse is caring for an adult who is enrolled in a study involving an experimental drug. The client says to the nurse, 'I don't think I can stand the vomiting anymore. I think it is due to the drug I am taking. If only I could get out of this study I signed up for. That was a really stupid thing I did when I signed up for the study.' What information must the nurse include when responding to the client?
- A. If the client signed the proper forms, the client is committed to the study.
- B. Persons who have signed up for a study may opt out of the study at any time.
- C. The person should discuss his/her concerns with the researchers.
- D. Inform the client that there are drugs that can control nausea.
Correct Answer: B
Rationale: Participants can withdraw from research studies at any time, per ethical research guidelines, ensuring autonomy and safety.
A three-year-old boy was shown to have delays on the Denver Development Screening Test (DDST).
Which of the following responses by the nurse is BEST?
- A. Maybe he is just having a bad day. I'm sure he will do much better next time.
- B. The Test indicated a delay and we will have to investigate to learn more.
- C. What are your thoughts about how your child performed on the Test ?
- D. The results may not be accurate. Let's set up a time to reTest your child.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates that fine discrimination is required. The topic of the questions is unstated. Determine topic by reading the answer choices. (1) nontherapeutic, false reassurance (2) factual but closed communication (3) correct-open-ended, encourages discussion (4) doesn't encourage discussion of concerns
The nurse is preparing a five-year-old child for surgery.
- A. What is the best action for the nurse when the informed consent for a five-year-old’s surgery is signed by the mother, and the parents are divorced with joint legal custody?
- B. Notify the physician.
- C. Inform surgery.
- D. Contact the father to obtain consent.
- E. Continue the child’s preoperative preparation.
Correct Answer: D
Rationale: In cases of joint legal custody, consent from either parent is sufficient for surgical procedures. Since the mother has signed the informed consent, no further action is needed, and the nurse should continue preoperative preparation. Notifying the physician, informing surgery, or contacting the father is unnecessary.
The nurse is teaching a client with a new diagnosis of type 1 diabetes about insulin aspart (NovoLog). Which of the following instructions should the nurse include?
- A. Take the insulin 30 minutes before meals.
- B. Mix the insulin with other insulins in the same syringe.
- C. Report any sweating or shakiness.
- D. Store the insulin at room temperature.
Correct Answer: C
Rationale: Sweating or shakiness indicate hypoglycemia, requiring reporting with insulin aspart. Options A, B, and D are incorrect.
A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident.
- A. Which symptom should the nurse expect initially in a client with a subdural hematoma and cerebral edema?
- B. Unequal and dilated pupils.
- C. Decerebrate posturing.
- D. Grand mal seizures.
- E. Decreased level of consciousness.
Correct Answer: D
Rationale: A decreased level of consciousness (e.g., confusion, stupor) is the initial symptom of increased intracranial pressure from a subdural hematoma, reflecting cerebral compression. Unequal pupils, posturing, and seizures are later signs of severe brain damage.