Nokea
The nurse is caring for a client diagnosed with polycythemia vera. Which statement by the client requires immediate follow-up?
- A. I am trying to find makeup to cover my unattractive, ruddy facial complexion
- B. I massage my sore leg to help bring the swelling down
- C. I take low-dose aspirin to relieve my occasional headaches
- D. My skin itches so severely, and no lotion or cream seems to help
Correct Answer: B
Rationale: Massaging a sore, swollen leg risks dislodging a clot in polycythemia vera, which predisposes to thrombosis. Ruddy complexion, aspirin use, and itching are expected but less urgent.
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The nurse is acting as a preceptor for a student nurse in the labor and delivery unit. Which action by the student would require correction by the nurse?
- A. Removing gloves prior to removing isolation gown
- B. Using a nail brush to scrub underneath artificial nails
- C. Using alcohol-based hand sanitizer instead of washing hands when entering and exiting client room
- D. Washing hands and not wearing gloves when preparing medications in the med room
Correct Answer: B
Rationale: Artificial nails harbor bacteria, and scrubbing underneath is inadequate; they should be avoided in labor and delivery. Other actions align with infection control protocols.
The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the following would the nurse expect at this age?
- A. Cooing
- B. Imitation of sounds
- C. Throaty sounds
- D. Laughter
Correct Answer: B
Rationale: Imitation of sounds. Eight-month-olds typically imitate sounds like 'da-da' as part of language development.
A client is admitted for treatment of hypoparathyroidism. Based on the client's diagnosis, the nurse would anticipate an order for:
- A. Potassium
- B. Magnesium
- C. Calcium
- D. Iron
Correct Answer: C
Rationale: The parathyroid is responsible for calcium and phosphorus absorption. Clients with hypoparathyroidism have hypocalcemia. Answers A, B, and D are not associated with hypoparathyroidism; therefore, they are incorrect.
After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first?
- A. Administer diphenhydramine
- B. Administer injectable epinephrine
- C. Examine the client's trunk and limbs
- D. Reassess the client's allergy history
Correct Answer: C
Rationale: Examining the trunk and limbs determines the rash’s extent, guiding whether it’s a mild reaction or a severe one (e.g., Stevens-Johnson syndrome). Diphenhydramine, epinephrine, or allergy reassessment are secondary until the rash is fully assessed.
What is the primary goal of family education?
- A. symptom reduction
- B. improved quality of life
- C. increased knowledge about mental illness
- D. improved caregiving skills
Correct Answer: B
Rationale: Improving quality of life is the primary goal of family education.