Nokea
The nurse is assessing cranial nerve XI. The nurse should:
- A. open a vial of cloves and ask the client to identify the scent.
- B. shine a flashlight in the client's eyes and observe the pupils.
- C. ask the client to shrug his shoulders.
- D. use the Snellen chart and have the client identify letters.
Correct Answer: C
Rationale: Cranial nerve XI (spinal accessory) controls neck and shoulder muscles; shoulder shrugging tests its function, unlike scent (I), pupil response (III), or vision (II).
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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.
The nurse is teaching a client who has short-term memory loss how to use the call light. Which factor is least essential for the nurse to assess when teaching this client?
- A. Visual status
- B. Ambulatory difficulty
- C. Orientation to time, place, and person
- D. Understanding of the English language
Correct Answer: B
Rationale: Ambulatory difficulty is least relevant, as call light use relies on vision, orientation, and language comprehension, not mobility.
The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is
- A. Drink 3000 to 4000 cc of fluid each day for one month.'
- B. Limit fluid intake to 1000 cc each day for one month.'
- C. Increase fluid intake for the next three days.'
- D. Restrict milk and dairy products for one month.'
Correct Answer: A
Rationale: Drink 3000 to 4000 cc of fluid each day for one month.' Drinking three to four quarts (3000 to 4000 cc) of fluid each day will aid passage of fragments and help prevent formation of new calculi.
The nurse is caring for a client with a history of seizures who is receiving phenytoin (Dilantin) 100 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I brush my teeth twice a day.
- B. I take my medication with milk.
- C. I have a rash on my arms.
- D. I feel drowsy in the morning.
Correct Answer: C
Rationale: A rash may indicate a hypersensitivity reaction to phenytoin, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate evaluation. Options A, B, and D are less concerning: brushing teeth is routine, milk does not affect absorption, and drowsiness is a common side effect.
A client is currently hospitalized with renal failure and has 3+ pitting edema of the lower extremities.
Which of the following nursing observations would indicate a therapeutic response to therapy for the edema?
- A. Serum potassium 4.0 mEq/L.
- B. Plasma glucose 140 mg/dL.
- C. Increased specific gravity of the urine.
- D. Weight loss of 5 lb over last two days.
Correct Answer: D
Rationale: Strategy: Determine how each answer choice relates to edema. (1) no relation to edema (2) no relation to edema (3) urine specific gravity may be decreased as client begins to lose some edema fluid (4) correct-edema is a result of sodium and fluid retention; weight loss should occur if therapy is effective