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The nurse in a long-term care facility is talking with a client with multiple sclerosis who states, 'I want to live in my own home again.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do you have family or friends who could live with you?
- B. I will refer you to a local home-health agency.
- C. How will you manage your care at home?
- D. Tell me more about your concerns.
Correct Answer: D
Rationale: Encouraging the client to express their concerns promotes client-centered care and helps the nurse understand the client's motivations and needs for returning home.
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The mother of a 4-month-old infant calls the physician's office reporting that her child has a temperature of 101°F and a rash that is blanchable and doesn't itch. What does the LPN expect will be ordered for this child?
- A. Aspirin
- B. Ibuprofen
- C. Acetaminophen
- D. Antibiotics
Correct Answer: C
Rationale: Acetaminophen is safe for fever in infants, addressing the temperature while the non-itchy, blanchable rash is monitored, likely viral.
The nurse reinforces teaching to a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis. Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include?
- A. Notify the health care provider if your urine is red
- B. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication
- C. Wear eyeglasses instead of soft contact lenses while taking this medication
- D. You can stop taking the medications as soon as one sputum culture comes back normal
Correct Answer: C
Rationale: Rifampin can stain soft contact lenses orange-red, so wearing eyeglasses prevents this issue, making it a key instruction for adherence.
The best method of evaluating the amount of peripheral edema is:
- A. Weighing the client daily
- B. Measuring the extremity
- C. Measuring the intake and output
- D. Checking for pitting
Correct Answer: B
Rationale: Measuring the extremity provides a direct and quantifiable assessment of peripheral edema by tracking changes in circumference. Daily weighing can indicate fluid retention but is less specific, so answer A is incorrect. Intake and output monitoring does not directly measure edema, so answer C is incorrect. Checking for pitting assesses the presence of edema but not its amount, so answer D is incorrect.
The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which findings as expected neurological changes for the client with a concussion? Select all that apply.
- A. Amnesia
- B. Asymmetrical pupillary constriction
- C. Brief loss of consciousness
- D. Headache
- E. Loss of vision
Correct Answer: A,C,D
Rationale: Amnesia (A), brief loss of consciousness (C), and headache (D) are common symptoms of concussion due to temporary brain dysfunction.
The nurse has assigned a nursing assistant to give the client a bath. Which observation reported by the nursing assistant requires immediate attention by the nurse?
- A. A red area on the back that disappears after it is massaged
- B. A red area on the hip that does not go away after the area is massaged
- C. The client's insistence on doing most of the bath
- D. The indwelling urethral catheter is draining clear, amber urine.
Correct Answer: B
Rationale: A non-blanching red area on the hip suggests a pressure injury, requiring immediate nursing intervention to prevent progression.