Nokea
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he:
- A. Avoids eating
- B. Rests in a recumbent position
- C. Eats a meal or snack
- D. Sits upright after eating
Correct Answer: C
Rationale: Duodenal ulcers cause pain relieved by eating due to buffering of gastric acid. Pain worsens when the stomach is empty. Resting or sitting upright does not directly relieve symptoms.
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A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:
- A. The client is restless.
- B. The elevated blood pressure causes photophobia.
- C. Noise or bright lights may precipitate a convulsion.
- D. External stimuli are annoying to the client with PIH.
Correct Answer: C
Rationale: The client may be anxious and hyperresponsive to stimuli but not necessarily restless. This is not a physiological response to an elevated blood pressure in PIH. The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. External stimuli might induce a convulsion but are not annoying to the client with PIH.
The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
- A. I will have blood drawn every month.'
- B. I will assess my skin for a rash.'
- C. I take aspirin for a headache.'
- D. I will use an electric razor to shave.'
Correct Answer: C
Rationale: Taking aspirin while on warfarin increases bleeding risk due to their combined anticoagulant effects. The client needs further teaching to avoid aspirin. Monthly blood draws (for INR), checking for rashes (a side effect), and using an electric razor (to reduce cuts) are appropriate.
A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:
- A. Dims the lights in her room
- B. Encourages her to breathe slowly and deeply
- C. Offers sips of warm liquids
- D. Places a large, soft pillow under her head
Correct Answer: A
Rationale: The discomfort of photophobia is alleviated by dimming the lights. Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis. It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
- A. Anemia and vomiting
- B. Polyuria and polydipsia
- C. Irritability relieved by feeding formula
- D. Hypothermia and azotemia
Correct Answer: B
Rationale: Anemia and vomiting are not cardinal signs of diabetes insipidus. Polyuria and polydipsia are the cardinal signs of diabetes insipidus. Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.
The nurse is educating a group of caregivers about the West Nile virus. A participant asks, 'How can you get the West Nile virus?' The nurse explains that the virus can be transmitted by which source(s)?
- A. Mosquitoes
- B. Blood transfusions
- C. Transplanted organs
- D. Birds
- E. Horses
Correct Answer: A, B, C
Rationale: West Nile virus is transmitted by mosquitoes (A), blood transfusions (B), and organ transplants (C). Birds (D) and horses (E) are hosts but not direct vectors to humans.