Nokea
The nurse is assessing a client with a suspected stroke. Which of the following findings is most indicative of a stroke?
- A. Sudden unilateral weakness.
- B. Gradual onset of headache.
- C. Bilateral leg pain.
- D. Chronic fatigue.
Correct Answer: A
Rationale: Sudden unilateral weakness is a classic sign of stroke due to impaired blood flow to one side of the brain.
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The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply.
- A. Ask the client to rub lotion over the hands every day after bathing.
- B. Encourage physical activity, such as ambulation.
- C. Provide frequent contacts for communication and socialization.
- D. Provide family education.
- E. Encourage involvement of family and friends.
Correct Answer: A,B,C,E
Rationale: Non-restrictive interventions like applying lotion, encouraging physical activity, providing social interaction, and involving family can address the behavior's underlying causes, such as anxiety or sensory needs, while promoting client autonomy and engagement.
A client with a history of type 1 diabetes mellitus is prescribed insulin detemir (Levemir). The nurse should explain that this insulin:
- A. Is taken as needed for high blood sugar.
- B. Provides a steady basal insulin level.
- C. Should be mixed with short-acting insulin.
- D. Is administered immediately before meals.
Correct Answer: B
Rationale: Insulin detemir provides a steady basal insulin level over 24 hours, used for long-term glucose control.
The nurse is caring for a neonate with jaundice receiving phototherapy. Which action is most important?
- A. Cover the neonate's eyes.
- B. Apply lotion to the skin.
- C. Keep the neonate swaddled.
- D. Monitor urine output daily.
Correct Answer: A
Rationale: Covering the neonate's eyes protects them from retinal damage due to phototherapy light exposure.
The nurse is visiting a client who has been prescribed topical clotrimazole. The nurse should educate the client to the fact that this medication will alleviate which condition?
- A. Pain
- B. Rash
- C. Fever
- D. Sneezing
Correct Answer: B
Rationale: Clotrimazole is a topical antifungal used in the treatment of cutaneous fungal infections and will alleviate an associated rash. The nurse teaches the client that it is used for this purpose. It is not used for pain, sneezing, or fever.
The nurse is caring for a client with a history of hyperthyroidism who is prescribed methimazole (Tapazole). The nurse should monitor the client for which of the following adverse effects?
- A. Agranulocytosis.
- B. Hypertension.
- C. Hyperglycemia.
- D. Weight loss.
Correct Answer: A
Rationale: Methimazole can cause agranulocytosis, a serious reduction in white blood cells, requiring monitoring.