Nokea
The nurse is administering alendronate (Fosamax) to an adult. Which instruction is necessary to give the client?
- A. Take medication with milk and a snack.
- B. Take medication after each meal.
- C. Sit up for at least 30 minutes after taking medication.
- D. Lie down for 30 minutes after taking medication.
Correct Answer: C
Rationale: Alendronate can cause esophageal irritation; sitting up for 30 minutes post-dose ensures proper passage and absorption, preventing reflux. Milk, meals, or lying down increase irritation risk.
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A client whose father died from Huntington's chorea asks what the chances are that he will develop the disease. The nurse knows that the chances of the client developing the disease are:
- A. 25%
- B. 50%
- C. 100%
- D. 0%
Correct Answer: B
Rationale: Huntington's disease is autosomal dominant; with one affected parent, the client has a 50% chance of inheriting the gene and developing the disease.
The nurse is caring for a client who is suffering from severe anxiety. What must the client do first when learning to deal with his anxiety?
- A. Recognize that he is feeling anxious
- B. Identify the situations that precipitated his anxiety
- C. Understand the reason for his anxiety
- D. Select a strategy to use to help him cope with his anxiety
Correct Answer: A
Rationale: Recognizing anxiety is the first step in managing it, enabling the client to address triggers, reasons, and coping strategies sequentially.
A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?
- A. Change the baby to whole milk
- B. Add chocolate syrup to the bottle
- C. Continue with the present formula
- D. Offer fruit juice frequently
Correct Answer: C
Rationale: Continue with the present formula. Switching to whole milk before 12 months can lead to allergies and lactose intolerance.
During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:
- A. Silver sulfadiazine (Silvadene)
- B. Poviodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Silver nitrate
Correct Answer: C
Rationale: Mafenide acetate (Sulfamylon) is particularly effective against Pseudomonas infections due to its broad-spectrum antibacterial activity and ability to penetrate eschar. Silver sulfadiazine is less effective against Pseudomonas, and povidone-iodine and silver nitrate are not the primary choices for Pseudomonas infections. Answers A, B, and D are incorrect because they are less effective for this specific infection.
Because a client has Guillain-Barré syndrome, the nurse would expect which of the following in the client's history?
- A. Recent upper respiratory infection
- B. A tick bite a few days ago
- C. A mosquito bite a week ago
- D. A strep throat infection two weeks ago
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral upper respiratory infection, triggering an autoimmune response, unlike tick bites, mosquito bites, or strep throat.