Nokea
The mother of an eight-month-old infant prepares to take her child home after treatment for bacterial meningitis. The mother confides to the nurse that she is afraid that her child will have brain damage as a result of his illness. Which of the following is the BEST response by the nurse?
- A. Trust your doctors. They are excellent pediatricians and will know what to look for.
- B. There is a 20% incidence of residual brain damage after this type of illness, but the odds are in your favor.
- C. It is an unlikely possibility, but if your child doesn't develop normally, your pediatrician will help you with any problems.
- D. You feel guilty about your son's illness, and that's understandable. You will feel better after you get home.
Correct Answer: C
Rationale: if treated early, good prognosis; may be complications and long-term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects), therapeutic response
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A 68-year-old woman comes to the outpatient clinic for a routine health screening. The nurse learns the client is a retired teacher who lives alone on a limited income. A history indicates the client drinks about 1,500 cc a day and her diet consists primarily of starches. It is MOST important for the nurse to encourage the client to
- A. increase her intake of protein.
- B. increase her intake of vitamins.
- C. reduce her caloric intake.
- D. reduce her fluid intake.
Correct Answer: A
Rationale: protein needed to slow down degeneration process of aging
The physician orders cholestyramine (Questran) 4 g PO qid for a 40-year-old client. The medication is provided in single-dose 4 g packets. The client asks the office nurse how to take the medication. The nurse should instruct the client to
- A. sprinkle the powder on a beverage, stir, and drink immediately.
- B. sprinkle the powder on food and eat slowly.
- C. add water to make a paste and eat, followed by 8 oz of water.
- D. sprinkle the powder on a beverage, let it stand a few minutes, and then stir and drink.
Correct Answer: D
Rationale: ensures uniform suspension
The nurse in a long-term care facility is reviewing the nurse's notes in a client's chart. The nurse would be MOST concerned by which of the following entries?
- A. Foley catheter draining clear urine and the pH is 6.5.
- B. The client's skin is blanched over the scapular areas.
- C. Vital signs are within normal limits.
- D. The client drinks three glasses of orange juice every day.
Correct Answer: B
Rationale: blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers
A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space
The nurse is caring for a client who is postoperative day 1 after a total abdominal hysterectomy. Which of the following findings should the nurse report immediately?
- A. Temperature of 100.4°F (38°C).
- B. Mild incisional pain.
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.4°F suggests infection, a serious postoperative complication. Options B, C, and D are expected findings.