Nokea
The nurse has taught the parents of a 6-year-old client with nephrotic syndrome. Which of the following statements by the parents would require follow-up?
- A. I will encourage my child to play with other children.
- B. I will monitor my child's urine for protein every day.
- C. I will provide a healthy diet without added salt for my child.
- D. I will report swelling or rapid weight gain to the health care provider.
Correct Answer: A
Rationale: Encouraging play with others (A) may expose the child to infections, risky in nephrotic syndrome due to immunosuppression. Monitoring urine (B), low-salt diet (C), and reporting swelling (D) are correct.
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The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?
- A. My pain is deep in my chest behind my breast bone.
- B. When I sit up the pain gets worse.
- C. As I take a deep breath the pain gets worse.
- D. The pain is right here in my stomach area.
Correct Answer: A
Rationale: My pain is deep in my chest behind my breast bone. This describes the typical substernal pain of acute angina.
The practical nurse is reinforcing discharge teaching to a client seen for treatment of a second episode of acute gout. Which instructions should be included to prevent future exacerbations? Select all that apply.
- A. Achieve and maintain a healthy weight
- B. Avoid diet sodas
- C. Avoid foods containing protein
- D. Drink plenty of fluids
- E. Restrict alcohol consumption
Correct Answer: A,D,E
Rationale: Healthy weight (A), hydration (D), and limiting alcohol (E) reduce uric acid levels and gout risk. Diet sodas (B) are not directly linked, and avoiding all protein (C) is unnecessary.
The school nurse is conducting an educational session for middle school teachers that is designed to heighten awareness of school bullying. The nurse recognizes that further instruction is needed when one of the teachers makes which comment?
- A. Bullying is a normal part of childhood growth and development.
- B. Children with physical disabilities are more vulnerable to bullying.
- C. Most children who are victims of a school bully do not tell an adult about it.
- D. The most common form of bullying is verbal aggression, such as insults and intimidation.
Correct Answer: A
Rationale: Bullying is not a normal part of development (A) and requires intervention. Vulnerability of disabled children (B), underreporting (C), and verbal aggression (D) are accurate.
The clinic nurse is reinforcing client teaching about the tiotropium that has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication?
- A. A capsule holds the powdered medication that I put in a special inhaler.
- B. I do not need to rinse my mouth out with water after taking tiotropium.
- C. I have been taking tiotropium every time I have difficulty breathing.
- D. Tiotropium helps control my COPD by reducing inflammation in my airway.
Correct Answer: A
Rationale: Tiotropium is a powder in a capsule used with an inhaler (A). Rinsing the mouth (B) is unnecessary, but it's taken daily, not PRN (C), and it's a bronchodilator, not anti-inflammatory (D).
A gravida para 1 reports that a prior pregnancy ended in loss of the baby early in the pregnancy. Which of the following instructions should be given to the client?
- A. She should refrain from sex during this pregnancy
- B. She should avoid stimulation of the breasts
- C. She should quit work until after the baby is born
- D. She should report any nausea and vomiting
Correct Answer: D
Rationale: Reporting nausea and vomiting is important, as severe symptoms could indicate complications like hyperemesis gravidarum, especially given the history of pregnancy loss.