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The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse?
- A. Do you have any questions about the diagnosis?
- B. There are medications available to treat Alzheimer disease.
- C. This new diagnosis must be frightening for you.
- D. We can help you make decisions about your care.
Correct Answer: C
Rationale: Acknowledging the emotional impact of the diagnosis validates the client's and spouse's feelings, fostering therapeutic communication and trust.
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A nurse is reinforcing appropriate interventions with the parent of an infant who had a febrile seizure. Which instruction is appropriate to review?
- A. Give acetaminophen or ibuprofen every 6-8 hours to control fever.
- B. Give the infant frequent tepid sponge baths to control the fever.
- C. If the infant develops another seizure, wait 15 minutes to see if it subsides.
- D. Place ice bags under the arms and around the neck to control fever.
Correct Answer: A
Rationale: Administering acetaminophen or ibuprofen every 6-8 hours helps control fever, reducing the risk of recurrent febrile seizures in infants.
Four clients were involved in a major highway motor vehicle accident. Which client requires priority care?
- A. Client with blood pressure of 90/70 mm Hg and deviated trachea
- B. Client with concussion who was unconscious for 5 minutes
- C. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg
- D. Client with pain at the thoracic spine and complete paralysis of both legs
Correct Answer: A
Rationale: A deviated trachea and hypotension suggest tension pneumothorax, a life-threatening condition requiring immediate decompression to restore breathing.
The nurse is documenting the assessment of a client's peripheral pulses. The nurse palpates the top portion of the client's feet and notes that the right pulse is full and strong, and the left pulse is diminished but still palpable. Which of the following would be correct documentation to include in the client's medical record?
- A. Bilateral dorsalis pedis pulses palpable. Right pulse 3+, left pulse 1+.
- B. Bilateral dorsalis pedis pulses palpable. Right pulse 4+, left pulse 2+.
- C. Bilateral popliteal pulses palpable. Right foot > left foot.
- D. Bilateral posterior tibial pulses palpable. Right pulse 3+, left pulse 1+.
Correct Answer: A
Rationale: The dorsalis pedis pulse is palpated on the top of the foot. A 3+ pulse is full and strong, and 1+ is diminished but palpable, accurately reflecting the findings.
Which of the following is responsible for laws mandating the reporting of certain infections and diseases?
- A. Centers for Disease Control and Prevention (CDC)
- B. individual state laws
- C. National Institute of Health Research (NIH)
- D. Health and Human Services (HHS)
Correct Answer: B
Rationale: Individual state laws mandate the reporting of infectious diseases. The list of reportable diseases varies from state to state and is overseen by state health departments.
The nurse has reinforced teaching for a client with newly diagnosed von Willebrand disease. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. I can use a humidifier to help prevent nosebleeds.
- B. I need to wear gloves while doing yard work.
- C. I should use a soft-bristled toothbrush and floss carefully.
- D. I will notify my health care provider if I soak a menstrual pad in an hour.
- E. I will take NAPROXEN to decrease pain and inflammation if I am injured.
Correct Answer: A,C,D
Rationale: Using a humidifier (A) prevents mucosal drying and nosebleeds. A soft-bristled toothbrush and careful flossing (C) minimize gum bleeding. Reporting heavy menstrual bleeding (D) is critical to manage bleeding risks in von Willebrand disease.