Nokea
The nurse has given instructions to a client who is returning home after an arthroscopy of the knee. The nurse determines that the client understands the home care instructions if the client states the need to follow which instruction?
- A. Resume strenuous exercise the following day.
- B. Stay off the leg entirely for the rest of the day.
- C. Refrain from eating food for the remainder of the day.
- D. Report fever or site inflammation to the primary health care provider.
Correct Answer: D
Rationale: After arthroscopy, signs/symptoms of infection should be reported to the primary health care provider. The client is instructed to avoid strenuous exercise for at least a few days; however, the client can usually walk carefully on the leg after sensation has returned. The client may resume the usual diet.
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The nurse is reviewing the medication history for a 24-year-old client in the fertility clinic. Which medication does the nurse understand to be a Category X medication in pregnancy?
- A. metformin
- B. amoxicillin
- C. gabapentin
- D. simvastatin
Correct Answer: D
Rationale: Simvastatin is Category X, contraindicated in pregnancy due to fetal harm. Others are safer (Categories B or C).
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.
The home care nurse suspects that a client's spouse is experiencing caregiver strain. Which action should the nurse take to assess for this condition?
- A. Referring the family to a social services agency
- B. Gathering data from the caregiver and the client
- C. Waiting for the caregiver to talk about the stress
- D. Obtaining feedback from the client about the caregiver
Correct Answer: B
Rationale: Caregiver strain can occur when a client is significantly dependent on the caregiver for personal and health care needs. The nurse gathers data from the client and the caregiver to determine the caregiver's stressors and coping abilities and withholds making any referrals until the assessment is complete and the plan of care is in place. Because the nurse suspects caregiver strain, the nurse fulfills the duty to the client and family by approaching the family with the concern, gathering assessment data, and planning care. The nurse does not expect the client to assess the coping abilities of the caregiver because assessment is part of the nursing process and should not be delegated.
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.
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.