Nokea
The nurse has reinforced teaching with a client with newly diagnosed psoriasis. Which of the following statements by the client would require follow-up?
- A. Exposure to sunlight will worsen my psoriasis.
- B. I should avoid scratching the lesions.
- C. Stress can worsen my psoriasis.
- D. I should avoid drinking alcohol.
Correct Answer: A
Rationale: Moderate sunlight exposure can improve psoriasis, so statement A is incorrect and requires follow-up. Avoiding scratching (B), recognizing stress as a trigger (C), and avoiding alcohol (D) are accurate and align with psoriasis management.
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The nurse is caring for a depressed client with a new prescription for a selective serotonin reuptake inhibitor (SSRI) antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?
- A. History of obesity
- B. Prescribed use of a monoamine oxidase (MAO) inhibitor
- C. Diagnosis of vascular disease
- D. Takes antacids frequently
Correct Answer: B
Rationale: SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.
The nurse monitoring a client with appendicitis will expect the client to give which description of the associated abdominal pain?
- A. A burning sensation; in the upper abdomen
- B. An 8 out of 10; on the left side below the belly button
- C. Excruciating; in the lower abdomen above the right hip
- D. Intermittent; in the abdomen and right shoulder
Correct Answer: C
Rationale: Appendicitis typically causes severe pain in the right lower quadrant (C). Upper abdominal burning (A) suggests gastritis, left-sided pain (B) is atypical, and shoulder pain (D) may indicate referred pain from other conditions.
The nurse is assisting in planning care for a client experiencing an acute attack of Ménière disease. Which action is a high priority to include in the plan of care?
- A. Initiate fall precautions
- B. Keep the emesis basin at bedside
- C. Provide a quiet environment
- D. Start IV fluids
Correct Answer: C
Rationale: A quiet environment (C) reduces sensory overload, a priority in Ménière disease attacks. Fall precautions (A), emesis basin (B), and IV fluids (D) are supportive but less critical.
The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.
The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization?
- A. Younger siblings adapt very well
- B. Visitation is helpful for both
- C. The siblings may enjoy privacy
- D. Those cared for at home cope better
Correct Answer: B
Rationale: Visitation is helpful for both. Contact with the ill child helps siblings understand hospitalization and maintain relationships.