Nokea
The nurse creates a teaching plan regarding the administration of eardrops for the parents of a 6-year-old child. The nurse tells the parents that, when administering the drops, which action is appropriate?
- A. Wear gloves.
- B. Pull the ear up and back.
- C. Hold the child in a sitting position.
- D. Position the child so that the affected ear is facing downward.
Correct Answer: B
Rationale: To administer eardrops in a child who is more than 3 years old, the ear is pulled upward and back. The ear is pulled down and back in children less than 3 years old. Gloves do not need to be worn by the parents, but hand washing before and after the procedure must be performed. The child needs to be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal with the help of gravity.
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The nurse is instructing a client diagnosed with type 1 diabetes mellitus about the management of hypoglycemic reactions. The nurse instructs the client that hypoglycemia most likely occurs during what time interval after insulin administration?
- A. Peak
- B. Onset
- C. Duration
- D. Anytime
Correct Answer: A
Rationale: Insulin reactions are most likely to occur during the peak time after insulin administration, when the medication is at its maximum action. Peak action depends on the type of insulin, the amount administered, the injection site, and other factors.
The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. What should the nurse do to appropriately test for asterixis?
- A. Examine the client's handwriting movements.
- B. Check the stool for clay-colored pigmentation.
- C. Ask the client to extend the wrist and the fingers.
- D. Check the serum bilirubin and liver enzyme levels.
Correct Answer: C
Rationale: Asterixis, or liver flap, is a rapid, nonrhythmic tremor in hepatic encephalopathy, tested by having the client extend the wrist and fingers. Handwriting is nonspecific, stool color is unrelated, and lab tests do not assess asterixis directly.
The community health nurse provides an educational session regarding the risk factors for cervical cancer to women in the local community. The nurse determines that further teaching is needed if a woman attending the session identifies which as a risk factor for this type of cancer?
- A. Smoking tobacco
- B. Single sex partner
- C. Early age of first intercourse
- D. Human papillomavirus (HPV) infection
Correct Answer: B
Rationale: Having a single sex partner is not a risk factor for cervical cancer. Some risk factors for cervical cancer include having multiple sexual partners or a partner who had multiple sexual partners, smoking tobacco, early age of first intercourse, and HPV infection.
The nurse is performing a socioeconomic assessment of an Asian client. Which questions are appropriate for the nurse to ask?
- A. What do you do for a living?
- B. How much money do you make yearly?
- C. Do you have a primary health care provider?
- D. How many years of school did you complete?
- E. How different is your life here from in your homeland?
- F. What type of work did you do back in your homeland?
Correct Answer: A,C,D,E,F
Rationale: Aspects to include in a cultural assessment include biocultural history and socioeconomic status (distinct health risks can be attributed to the ecological and socioeconomic context of the culture) and the client's country of origin. Other aspects to assess include religious and spiritual beliefs, communication patterns, time orientation, caring beliefs and practices, and previous experiences with professional health care. Some specific questions to ask when performing a socioeconomic assessment are noted in the correct options. Asking the client about his or her yearly income is inappropriate, unnecessary, and unrelated to health care resources.
The nurse is caring for a client diagnosed with syphilis. The client presents with a widespread, symmetric maculopapular rash on the palms and soles. The nurse understands that the client is in which stage of the infection?
- A. primary syphilis
- B. secondary syphilis
- C. early latent syphilis
- D. latent phase syphilis
Correct Answer: B
Rationale: A maculopapular rash on palms and soles is characteristic of secondary syphilis, following the primary chancre.