Nokea
The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?
- A. Report a persistent cough to the health care provider
- B. The child can return to school in 4 days
- C. Administer chewable aspirin for pain
- D. The child may gargle with saline as necessary for discomfort
Correct Answer: A
Rationale: Report a persistent cough to the health care provider. Persistent coughing may indicate bleeding, which requires immediate attention.
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The nurse is caring for a client with suspected colorectal cancer. Which of the following findings would support a diagnosis of colorectal cancer? Select all that apply.
- A. Fatigue
- B. Blood in the stool
- C. Change in bowel habits
- D. Unintentional weight loss
- E. Elevated hemoglobin level
Correct Answer: A,B,C,D
Rationale: Colorectal cancer often presents with fatigue (A) due to anemia or systemic effects, blood in the stool (B) from tumor bleeding, changes in bowel habits (C) like diarrhea or constipation, and unintentional weight loss (D) from malignancy-related cachexia. Elevated hemoglobin (E) is unlikely, as anemia is more common due to chronic blood loss.
A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply.
- A. Difficult to awaken
- B. Dry skin
- C. Frequent, loose stools
- D. Hoarse cry
- E. Tachycardia
Correct Answer: A,B,D
Rationale: Hypothyroidism in infants causes lethargy (A), dry skin (B), and hoarse cry (D) due to slowed metabolism. Loose stools (C) and tachycardia (E) are more typical of hyperthyroidism.
Which of the following indicates that the client taking an anticoagulant needs further teaching?
- A. The client states that he will report bruising
- B. The client states that he eats green, leafy vegetables at least three times weekly
- C. The client states that he will return to the doctor's office for scheduled lab work
- D. The client states that his insulin dose might have to be adjusted while he is taking an anticoagulant
Correct Answer: B
Rationale: Green, leafy vegetables are high in vitamin K, which can counteract anticoagulants like warfarin, so consistent intake or dietary counseling is needed.
A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
- A. Encourage the visitor to lie down to see if symptoms change
- B. Initiate protocol to assist the visitor to the emergency department
- C. Proceed to take the visitor's blood pressure
- D. Suggest that the visitor call the health care provider
Correct Answer: B
Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
The nurse is reviewing lifestyle and nutritional strategies to help cables symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply.
- A. Choose foods that are low in fat
- B. Do not consume any foods containing dairy
- C. Eat three large meals a day and minimize snacking
- D. Limit or eliminate the use of alcohol and tobacco
- E. Try to avoid caffeine, chocolate, and peppermint
Correct Answer: A,D,E
Rationale: GERD management focuses on reducing esophageal irritation. Low-fat foods (A) reduce gastric acid secretion and reflux risk. Limiting alcohol and tobacco (D) prevents lower esophageal sphincter relaxation and mucosal irritation. Avoiding caffeine, chocolate, and peppermint (E) minimizes sphincter relaxation. Dairy (B) is not universally contraindicated unless lactose intolerance is present. Large meals (C) increase gastric pressure, worsening reflux.