Nokea
The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
- A. "Alcohol is not contraindicated while taking this medication."
- B. "Good oral hygiene is needed, including brushing and flossing."
- C. "The medication dose may be self-adjusted depending on side effects."
- D. "The morning dose of the medication should be taken before a serum drug level is drawn."
Correct Answer: B
Rationale: Phenytoin (Dilantin) can cause gingival hyperplasia, a side effect manifested by overgrowth of the gums. To help prevent this side effect, patients taking phenytoin should maintain good oral hygiene practices, including regular brushing and flossing. This statement shows an understanding of the importance of oral care while on phenytoin therapy, making it the correct answer choice.
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The nurse is caring for a high-risk newborn with an umbilical catheter in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action?
- A. Elevate feet 15 degrees.
- B. Place socks on newborn.
- C. Wrap feet loosely in prewarmed blanket.
- D. Report findings immediately to the practitioner.
Correct Answer: C
Rationale: When the nurse notes blanching of the feet in a high-risk newborn with an umbilical catheter in a radiant warmer, the most appropriate nursing action is to wrap the feet loosely in a prewarmed blanket. Blanching indicates poor circulation to the area, which can be a result of cold stress or constriction of blood vessels. By wrapping the feet in a prewarmed blanket, the nurse can help to restore adequate blood flow to the feet and improve circulation. This action addresses the potential cause of the blanching and promotes the newborn's comfort and well-being.
Which communication technique should the nurse avoid when interviewing children and their families? TestBankWorld.org
- A. Using silence
- B. Using cliche
- C. Directing the focus
- D. Defining the problem
Correct Answer: C
Rationale: When interviewing children and their families, nurses should avoid directing the focus. Directing the focus involves steering the conversation in a certain direction, which may hinder open communication and the exploration of important issues. It is essential to allow children and their families to express themselves freely and openly, which can lead to a more comprehensive understanding of their perspectives and needs. Avoiding directing the focus can help build trust and rapport with the children and their families, leading to more effective communication and care.
Fred is a 12-year-old boy diagnosed with pneumococcal pneumonia. Which of the following would Nurse Nica expect to assess?
- A. Mild cough
- B. Slight fever
- C. Chest pain
- D. Bulging fontanel
Correct Answer: C
Rationale: Pneumococcal pneumonia often presents with symptoms such as chest pain due to inflammation of the lung tissue. In children, chest pain may be a common symptom alongside other signs like fever, cough, and difficulty breathing. Since Fred has been diagnosed with pneumococcal pneumonia, Nurse Nica would expect to assess him for chest pain as part of the typical presentation of this condition in children.
Which of the ff conditions is evident by persistent hoarseness?
- A. Bacterial infection
- B. Aphonia
- C. Laryngeal cancer
- D. Peritonsillar abscess
Correct Answer: C
Rationale: Persistent hoarseness is often a symptom of laryngeal cancer. Laryngeal cancer affects the voice box, leading to changes in voice quality, such as hoarseness. It is important to seek medical evaluation if hoarseness lasts for more than two weeks, as early detection and treatment of laryngeal cancer can improve outcomes. Bacterial infection, aphonia (loss of voice), and peritonsillar abscess are not typically associated with persistent hoarseness as a primary symptom.
Nurse Beverly is giving preoperative instructions to Ian who is scheduled for an Ileostomy. Which of the following would be included?
- A. "Your urine will be collected in a pouch following surgery."
- B. "You will have a nasogastric tube after surgery."
- C. "Your bowel will be visualized with a laparoscope during surgery."
- D. "You can drink liquids within 24 hours after surgery."
Correct Answer: A
Rationale: An ileostomy is a surgical procedure that involves creating a stoma from the ileum (part of the small intestine) to the abdominal wall, allowing waste to bypass the colon and exit the body through the stoma into a pouch worn on the outside of the body. Therefore, it is important for Nurse Beverly to inform Ian that his stool output will be collected in a pouch following the surgery. Option A is the correct choice as it directly relates to the postoperative care and management specific to an ileostomy procedure.