Nokea
The nurse in an ambulatory clinic administers a tuberculin skin test to a client on a Monday. When should the nurse tell the client to return to the clinic to have the results read?
- A. Thursday or Friday
- B. The following Monday
- C. Tuesday or Wednesday
- D. Wednesday or Thursday
Correct Answer: D
Rationale: The tuberculin skin test for tuberculosis is read in 48 to 72 hours; therefore, the client should return to the clinic on Wednesday or Thursday.
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The community health is conducting a health screening clinic. The nurse interprets that which client participating in the screening is the highest priority client to provide instruction to lower the risk of developing respiratory disease?
- A. A smoker who works in an acute care hospital
- B. A person who works with lawn care pesticides
- C. A person who does woodworking as a hobby for 8 years
- D. A smoker who has cracked asbestos lining on the basement pipes
Correct Answer: D
Rationale: The client who smokes and has exposure to cracked asbestos lining is at the highest risk for respiratory disease due to the combined effects of smoking and asbestos, both potent lung irritants. Smoking alone or other exposures (pesticides, woodworking) pose risks, but the dual exposure in option D is the most severe.
The nurse makes a home care visit to a client diagnosed with Bell's palsy. Which statement by the client indicates a need for further teaching?
- A. I wear an eye patch at night.
- B. I am staying on a liquid diet.
- C. I wear dark glasses when I go out.
- D. I have been gently massaging my face.
Correct Answer: B
Rationale: Bell's palsy is caused by a lower motor neuron lesion of the seventh cranial nerve that may result from infection, trauma, hemorrhage, meningitis, or tumor. It is not necessary for a client diagnosed with Bell's palsy to stay on a liquid diet. The client should be encouraged to chew on the unaffected side. Wearing an eye patch at night, dark glasses for daytime outings, and gently massaging the face identify accurate statements related to the management of Bell's palsy.
A client is given a prescription for an antipsychotic medication. The nurse instructs the client and family to report any signs/symptoms of pseudoparkinsonism and tells the family to monitor for what effects indicative of this medication complication?
- A. Tremors and hyperpyrexia
- B. Motor restlessness and aphasia
- C. Stooped posture and a shuffling gait
- D. Muscle weakness and decreased salivation
Correct Answer: C
Rationale: Pseudoparkinsonism is a common extrapyramidal side effect of antipsychotic medications. This condition is characterized by a stooped posture, a shuffling gait, a masklike facial appearance, drooling, tremors, and pill-rolling motions of the fingers. Hyperpyrexia is characteristic of the extrapyramidal side effect of neuroleptic malignant syndrome. Motor restlessness, aphasia, muscle weakness, and decreased salivation are not characteristic of pseudoparkinsonism.
The labor and delivery nurse notes that the health care provider has rated a newborn's Apgar score as 9. The nurse understands which to be true regarding Apgar scores?
- A. The optimum score is 10.
- B. A baby with poor activity would rate a 1 in that area.
- C. The highest score that each factor may receive is 3.
- D. Scores are obtained 5 minutes after birth and repeated 5 minutes later.
Correct Answer: A
Rationale: The optimal Apgar score is 10. Each factor scores 0-2, and scores are taken at 1 and 5 minutes post-birth.
The mother of a child with celiac disease asks the nurse how long a special diet is necessary. The nurse provides which instruction to the mother to promote dietary compliance?
- A. A gluten-free diet will need to be followed for life.
- B. A lactose-free diet will need to be followed temporarily.
- C. Added dietary sodium will help prevent episodes of celiac crisis.
- D. Supplemental vitamins, iron, and folate will prevent complications.
Correct Answer: A
Rationale: Celiac disease is characterized by intolerance to gluten, the protein component of wheat, barley, rye, and oats. The main nursing consideration with celiac disease is helping the child adhere to dietary management. The treatment of celiac disease consists primarily of dietary management with a gluten-free diet. Options 2 and 4 are true statements, but they do not answer the question that the client is asking. Children with untreated celiac disease may have lactose intolerance, which usually improves with gluten withdrawal. Additional sodium does not prevent celiac crisis. Low levels of potassium, calcium, and magnesium are most likely to be present. Nutritional deficiencies resulting from malabsorption are treated with appropriate supplements.