Nokea
The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who? Select all that apply.
- A. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy.
- B. Has episodes of vertigo that result in falls.
- C. Has multiple sclerosis with an open, draining lesion on a foot.
- D. Needs stronger lenses for glasses.
Correct Answer: A,B,C
Rationale: Clients requiring prothrombin time monitoring, those with vertigo causing falls, and those with open lesions qualify for home care due to medical needs. Needing glasses does not typically require skilled home care services.
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The nurse is working on discharge plans with a client who is diagnosed with intermittent explosive disorder, characterized by sudden angry outbursts. The nurse determines that the client is ready for discharge when he makes which of the following comments?
- A. I'm just not going to let myself get angry anymore.'
- B. Spilling doesn't help, but I like being with my buddies at the bar.'
- C. I'll be taking valproic acid (Depakote) and propranolol (Inderal) to help stay in control.'
- D. It would help if my mom would stop getting on my case all the time.'
Correct Answer: C
Rationale: Understanding the role of medications (valproic acid and propranolol) in controlling outbursts indicates readiness for discharge in managing intermittent explosive disorder.
A client is receiving chemotherapy and reports nausea. The nurse should administer which of the following medications as prescribed?
- A. Ondansetron (Zofran).
- B. Diphenhydramine (Benadryl).
- C. Acetaminophen (Tylenol).
- D. Ibuprofen (Advil).
Correct Answer: A
Rationale: Ondansetron is an antiemetic commonly used to manage chemotherapy-induced nausea.
The nurse is caring for a client who has been diagnosed with pernicious anemia. Which of the following statements by the client indicates an understanding of the treatment of pernicious anemia?
- A. I will need to increase my dietary intake of foods that are high in vitamin B12.'
- B. I will receive my first injection of vitamin B12 tomorrow, and I will return for a follow-up injection in 1 month.'
- C. I understand that the oral form of vitamin B12 is preferred because it is safer and less expensive than the injection form.'
- D. I will need to take vitamin B12 replacements for the rest of my life.'
Correct Answer: D
Rationale: Pernicious anemia requires lifelong vitamin B12 injections due to intrinsic factor deficiency, preventing absorption of dietary or oral B12.
Which of the following abnormal serum chemistry results is a client with cirrhosis who has developed ascites likely to have?
- A. Decreased aspartate aminotransferase.
- B. Hypoalbuminemia.
- C. Hyperkalemia.
- D. Decreased alanine aminotransferase.
Correct Answer: B
Rationale: Cirrhosis impairs liver protein synthesis, leading to hypoalbuminemia, which causes ascites due to decreased oncotic pressure.
A client with a history of myocardial infarction is prescribed aspirin. What is the primary purpose of this medication?
- A. Reduce fever.
- B. Prevent platelet aggregation.
- C. Relieve chest pain.
- D. Lower cholesterol.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of thrombus formation in clients with a history of myocardial infarction.