Nokea
The nurse assesses cranial nerve XII in the client who sustained a stroke. Which action should the nurse ask the client to perform?
- A. Extend the arms.
- B. Extend the tongue.
- C. Turn the head toward the nurse's arm.
- D. Focus the eyes on an object held by the nurse.
Correct Answer: B
Rationale: Cranial nerve XII (hypoglossal) controls tongue movement, so extending the tongue tests its function. Other actions test different nerves or motor functions, not relevant to cranial nerve XII.
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The labor and delivery nurse expects which clients to be at high risk for amniotic fluid embolus (AFE)? Select all that apply.
- A. a 27-year-old client with preeclampsia
- B. a healthy 23-year-old anticipating a vaginal delivery
- C. a 42-year-old expecting her second child via cesarean section
- D. a 32-year-old client with diabetes anticipating induced labor
Correct Answer: A,C,D
Rationale: Preeclampsia, cesarean section, and induced labor increase AFE risk due to uterine trauma or hyperstimulation. A healthy vaginal delivery has lower risk.
The nurse teaches a client with hypertension to recognize the signs/symptoms that may occur during periods of elevated blood pressure. The nurse determines that the client needs additional teaching if the client states that which sign/symptom is associated with this condition?
- A. Epistaxis
- B. Dizziness
- C. Blurred vision
- D. A feeling of fullness in the head
Correct Answer: D
Rationale: A feeling of fullness in the head is more likely associated with a sinus condition than hypertension. Cerebrovascular symptoms of hypertension include early morning headaches, occipital headaches, epistaxis, dizziness, blurred vision, lightheadedness, and vertigo. The client should be aware of these signs/symptoms and report them if they occur. The client should also be taught to self-monitor the blood pressure.
Allopurinol has been prescribed for a client to treat gouty arthritis. The nurse teaches the client to anticipate which prescription if an acute attack occurs?
- A. Doubling the dose of the allopurinol
- B. Stopping the allopurinol and taking acetylsalicylic acid (aspirin)
- C. Stopping the allopurinol and taking a nonsteroidal anti-inflammatory drug
- D. Adding colchicine or a nonsteroidal anti-inflammatory drug to the treatment plan
Correct Answer: D
Rationale: Allopurinol helps prevent an attack of gouty arthritis, but it does not relieve the pain. Therefore, another medication such as colchicine or a nonsteroidal anti-inflammatory drug must be added if an acute attack occurs. Because acute attacks may occur more frequently early during the course of therapy with allopurinol, some health care providers recommend taking the two products concurrently during the first 3 to 6 months.
The nurse is providing discharge instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. To prevent complications of the surgical procedure, what should be the appropriate response to the mother?
- A. In 1 week.
- B. In 3 weeks.
- C. Six days after surgery.
- D. When the primary health care provider says it is okay.
Correct Answer: B
Rationale: Rough or scratchy foods, as well as spicy foods, are to be avoided for 3 weeks after a tonsillectomy. Citrus juices that irritate the throat should be avoided for 10 days. Red liquids are avoided because they will give the appearance of blood if the child vomits. The mother is instructed to add full liquids on the second day and soft foods as the child tolerates them.
A mother brings her 6-month-old child to the clinic for a wellness checkup. The nurse anticipates that the health care provider will order which vaccinations for this client?
- A. DTaP and MMR
- B. Hib and varicella
- C. hepatitis B and DTaP
- D. hepatitis A and MMR
Correct Answer: C
Rationale: At 6 months, hepatitis B and DTaP are scheduled. MMR, varicella, and hepatitis A are given later (12-15 months).