Nokea
The nurse is caring for a client recently diagnosed with AIDS. Which of the following interventions by the nurse would be BEST?
- A. Inspect the skin daily for signs of breakdown.
- B. Limit the number of health care personnel caring for the patient.
- C. Utilize standard precautions when administering parenteral medications.
- D. Monitor the patient's vital signs q4h.
Correct Answer: B
Rationale: implementation, decreases exposure to microorganisms
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The nurse is teaching a client with a new diagnosis of Parkinson’s disease about levodopa-carbidopa (Sinemet). Which of the following instructions should the nurse include?
- A. Take the medication with a high-protein meal
- B. Report any uncontrolled movements
- C. Stop the medication if symptoms improve
- D. Avoid regular neurological exams
Correct Answer: B
Rationale: Uncontrolled movements, such as dyskinesias, are a side effect of levodopa-carbidopa, requiring dose adjustment. Options A, C, and D are incorrect: high-protein meals reduce absorption, stopping the medication risks symptom return, and exams are essential.
A 19-year-old college student has a Mantoux test performed at the college health clinic. The result is positive. The clinic nurse should
- A. refer the student to an appropriate center for further testing.
- B. restrict the student's activity until his parents can be notified.
- C. notify the local Public Health Department.
- D. place the student in an isolation room in the college infirmary.
Correct Answer: A
Rationale: will perform chest x-ray
An 8-year-old boy is brought to the physician’s office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial rash on the trunk of his body. Which of the following assessments would be MOST important for the nurse to perform?
- A. Grasp the child’s hands and ask him to squeeze the nurse’s hands.
- B. Stroke the plantar surface of the child’s foot with a reflex hammer.
- C. Gently flex the child’s head and neck onto the chest.
- D. Have the child stand with his eyes closed, his arms at his sides, and his feet and knees close together.
Correct Answer: C
Rationale: Fever, headache, nausea, and petechial rash suggest meningitis; flexing the neck (Brudzinski’s sign) assesses meningeal irritation, a priority. Options A, B, and D are less relevant: hand squeeze is nonspecific, Babinski’s sign is not indicated, and Romberg’s sign assesses balance.
A 5-year-old boy is brought to the emergency room after ingesting a bottle of baby aspirin. The nurse should observe the boy for which of the following signs and symptoms?
- A. Nausea and vertigo.
- B. Epistaxis and paralysis.
- C. Dysrhythmia and hypoventilation.
- D. Tinnitus and gastric distress.
Correct Answer: D
Rationale: symptoms of overdose
The nurse is caring for a client receiving treatment for hypoparathyroidism. The nurse determines that treatment has been successful if which of the following was observed?
- A. The client's output is 1500 cc of clear straw-colored urine.
- B. The client is unable to state his name.
- C. The client denies numbness and tingling.
- D. The client loses 3 pounds in one week.
Correct Answer: C
Rationale: Hypoparathyroidism causes hypocalcemia, leading to numbness and tingling. Their absence indicates successful calcium therapy. Options A, B, and D are unrelated or indicate other issues.