Nokea
The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate?
- A. Fish
- B. Dog
- C. Cat
- D. Bird
Correct Answer: A
Rationale: Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold.
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A client with a history of cirrhosis is admitted with hepatic encephalopathy. The nurse should include which of the following in the plan of care?
- A. Administer lactulose as prescribed.
- B. Encourage a high-protein diet.
- C. Restrict fluid intake.
- D. Administer sedatives for agitation.
Correct Answer: A
Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy.
The nurse is caring for a client with a history of peripheral artery disease. Which of the following interventions is most appropriate?
- A. Keep the legs elevated above heart level.
- B. Encourage prolonged standing.
- C. Apply warm compresses to the legs.
- D. Promote regular walking.
Correct Answer: D
Rationale: Regular walking promotes collateral circulation in peripheral artery disease, improving blood flow.
After explaining to a multigravid client at 36 weeks' gestation who is diagnosed with severe hydramnios about the possible complications of this condition, which of the following statements indicates that the client needs further instruction?
- A. Because I have hydramnios, I may gain weight.'
- B. Hydramnios has been associated with gastrointestinal disorders in the fetus.'
- C. I should continue to eat high-fiber foods and avoid constipation.'
- D. I can continue to work at my job at the automobile factory until labor starts.'
Correct Answer: D
Rationale: Severe hydramnios increases risks like preterm labor, requiring activity restrictions; continuing physically demanding work indicates a need for further teaching.
A postoperative nursing goal for the infant who has had surgery to correct imperforate anus is to prevent tension on the perineum. To achieve this goal, the nurse should not place the neonate on the:
- A. Abdomen, with legs pulled up under the body.
- B. Back, with legs suspended at a 90-degree angle.
- C. Left side, with hips elevated.
- D. Right side, with hips elevated.
Correct Answer: A
Rationale: The abdominal position with legs tucked increases perineal tension, risking surgical site strain, unlike the other positions.
The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include:
- A. Kussmaul's respirations
- B. Excessive hunger
- C. Dry, flaky skin
- D. High blood pressure
Correct Answer: A
Rationale: Kussmaul's respirations (rapid, deep breathing) are a hallmark of diabetic ketoacidosis as the body compensates for acidosis. Excessive hunger is more typical of hypoglycemia, and dry skin or hypertension are less specific.