Nokea
The nurse has reinforced teaching with a client with newly diagnosed polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I should take an iron supplement daily.'
- B. I should increase my daily fluid intake.'
- C. I may require frequent phlebotomy.'
- D. I will take a low-dose aspirin daily.'
Correct Answer: A
Rationale: Iron supplements (A) can worsen polycythemia vera by increasing red blood cell production, requiring follow-up. Increased fluids (B), phlebotomy (C), and aspirin (D) are appropriate.
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A woman has recently been diagnosed with multiple sclerosis. Which comment by the client indicates that she understands the nature of the disease process?
- A. I understand that recovery will be slow.'
- B. I am faithfully taking the medicines so the symptoms should disappear soon.'
- C. I will avoid being close to my grandchildren until I have been on medication for several months.'
- D. I bought a pretty cane to help me with balance when I am walking.'
Correct Answer: D
Rationale: Using a cane for balance shows understanding of multiple sclerosis' chronic, progressive nature causing mobility issues, unlike expecting full recovery or avoiding grandchildren.
The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply.
- A. Depressed anterior fontanelle
- B. High-pitched cry
- C. Poor feeding
- D. Presence of the Babinski sign
- E. Vomiting
Correct Answer: B, C, E
Rationale: High-pitched cry (B), poor feeding (C), and vomiting (E) are signs of bacterial meningitis in infants. A depressed fontanelle (A) suggests dehydration, not meningitis, and Babinski sign (D) is normal in infants.
The nurse is reinforcing teaching about home administration of sublingual nitroglycerin tablets to a client with stable angina. Which client statement indicates the need for further teaching?
- A. I can take 1 tablet every 5 minutes, up to 3 times, for chest pain.'
- B. I should call 911 if my chest pain isn't relieved by nitroglycerin.'
- C. I will call my doctor's office if I start experiencing chest pain at rest.'
- D. I will keep one bottle of nitroglycerin in the house and one in the car.'
Correct Answer: D
Rationale: Keeping nitroglycerin in a car (D) risks exposure to heat, reducing efficacy, requiring further teaching. Other statements (A, B, C) are correct.
The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, 'With my spouse dead, there's no reason for me to go on.' What is the best response by the nurse?
- A. Are you having any thoughts of hurting yourself?'
- B. Do you have any friends in the building?'
- C. Tell me more about how you're feeling.'
- D. You're not thinking of killing yourself, are you?'
Correct Answer: A
Rationale: The client's statement and behavior suggest suicidal ideation. Directly asking about thoughts of self-harm (A) is the most appropriate response to assess risk and ensure safety. Options B, C, and D are less direct and may delay critical intervention.
The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time?
- A. Client admitted with Guillain-Barré syndrome yesterday is paralyzed to the knees
- B. Client admitted with multiple sclerosis exacerbation has scanning speech
- C. Client with epilepsy puts on call light and reports having an aura
- D. Client with fibromyalgia reports pain in the neck and shoulders
Correct Answer: C
Rationale: An aura (C) indicates an impending seizure, requiring immediate intervention to ensure safety. Guillain-Barré (A), multiple sclerosis (B), and fibromyalgia (D) are less acute at this moment.