Nokea
The nurse is administering hygienic care to an elderly client in her home. What should the nurse wash first?
- A. Perineal area
- B. Face
- C. Upper torso
- D. Hands
Correct Answer: B
Rationale: Washing the face first during hygienic care respects client comfort and dignity, starting with a less invasive area. It also prevents cross-contamination from dirtier areas like the perineum.
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Which of the following cutaneous manifestations is associated with Lyme disease?
- A. Annular rash
- B. Papular crusts
- C. Bullae
- D. Plaques
Correct Answer: A
Rationale: Lyme disease is characterized by an annular (erythema migrans) rash, often with a bull's-eye appearance, at the site of the tick bite.
A client is prescribed warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse's discharge instruction?
- A. Maintain a consistent intake of green leafy foods
- B. Report any nose or gum bleeds
- C. Take Tylenol for minor pains
- D. Use a soft toothbrush
Correct Answer: B
Rationale: Report any nose or gum bleeds. The client should notify the health care provider if blood is noted in stools or urine, or any other signs of bleeding occur.
The practical nurse assists in the care of a client who was admitted in a state of acute psychosis after ingesting recreational substances. The parents ask the nurse if the client will develop schizophrenia. Which response by the nurse is appropriate?
- A. I know it must be terrible to see your child like this, but your child will be fine within a few days.
- B. It is important to understand that most people have permanent adverse effects after an episode like this.
- C. We cannot predict whether your child will develop schizophrenia; close observation is required to determine the cause of psychosis.
- D. Your child would be fine right now if they had not taken these drugs. We will need to do some additional testing
Correct Answer: C
Rationale: Schizophrenia risk cannot be predicted from a single episode; observation is needed. Reassurance , permanent effects , and blame are inaccurate.
A patient has been ordered to get Klonapin for the first time. Which of the following side effects is not associated with Klonapin?
- A. Drowsiness
- B. Ataxia
- C. Salivation elevated
- D. Diplopia
Correct Answer: D
Rationale: A-C are associated side effects of Klonapin.
The registered nurse (RN) is making decisions regarding client room assignments on a pediatric unit. Which possible roommate would be most appropriate for a 3 year-old child with minimal change nephrotic syndrome?
- A. 2 year-old with respiratory infection
- B. 3 year-old fracture whose sibling has chickenpox
- C. 4 year-old with bilateral inguinal hernia repair
- D. 6 year-old with a sickle cell anemia crisis
Correct Answer: C
Rationale: Children with nephrotic syndrome are at high risk for development of infections as a result of the standard use of immunosuppressant therapy, as well as from the accumulation of fluid (edema). Therefore, these children must be protected from sources of possible infection.