Nokea
The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:
- A. Using a water pik
- B. Rinsing with water
- C. Rinsing with hydrogen peroxide
- D. Rinsing with baking soda
Correct Answer: A
Rationale: This technique provides effective rinsing and gingival stimulation. This technique does not provide gingival stimulation. This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. This technique provides effective rinsing but not gingival stimulation.
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A client with gallstones and obstructive jaundice is experiencing severe itching. The physician has prescribed cholestyramine (Questran). The client asks, “How does this drug work?” What is the nurse’s best response?
- A. “It blocks histamine, reducing the allergic response.”
- B. “It inhibits the enzyme responsible for bile excretion.”
- C. “It decreases the amount of bile in the gallbladder.”
- D. “It binds with bile acids and is excreted in bowel movements with stool.”
Correct Answer: D
Rationale: Cholestyramine binds bile acids in the intestine, forming complexes excreted in stool, reducing circulating bile acids that cause itching. It doesn’t block histamine (A), inhibit enzymes (B), or reduce gallbladder bile (C).
The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate a need for further teaching?
- A. "I should take the medication immediately before bedtime every night."
- B. "I should remain in an upright position for 30 minutes after taking Fosamax."
- C. "The medication should be taken by mouth with water."
- D. "I should not have any food with this medication."
Correct Answer: A
Rationale: Alendronate should be taken in the morning on an empty stomach, not before bedtime (A), indicating a need for further teaching. Upright positioning (B), taking with water (C), and avoiding food (D) are correct.
Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client's history?
- A. Menarche after age 13
- B. Nulliparity
- C. Maternal family history of breast cancer
- D. Early menopause
Correct Answer: C
Rationale: Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier. Average age for menarche is 12.5 years. Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater risk. A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast cancer. Early menopause decreases the risk of developing breast cancer.
The mother of a one-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurse's response is based on the knowledge that:
- A. There is no test to measure abnormal hemoglobin in newborns.
- B. Infants do not have insensible fluid loss before a year of age.
- C. Infants rarely have infections that would cause them to have a sickling crises.
- D. The presence of fetal hemoglobin protects the infant.
Correct Answer: D
Rationale: Fetal hemoglobin (HbF), predominant in newborns, inhibits sickling in sickle cell anemia, delaying symptoms until HbF decreases around 6 months. Newborn screening exists, and infections can trigger crises later.
An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:
- A. Inspiratory stridor and harsh cough
- B. Strident cough and drooling
- C. Wheezing and intercostal retractions
- D. Expiratory wheezing and nonproductive cough
Correct Answer: A
Rationale: Acute laryngotracheobronchitis (croup) typically presents with inspiratory stridor and a harsh, barking cough due to subglottic airway inflammation.