Nokea
The nurse is caring for a client who has bacterial meningitis. Which of the following actions should the nurse take? Select all that apply.
- A. Minimize environmental stimuli.
- B. Implement seizure precautions.
- C. Maintain the head of bed at 30 degrees.
- D. Keep a surgical mask on the client at all times.
- E. Place the client in a room with monitored negative air pressure.
Correct Answer: A, B, C
Rationale: Minimizing stimuli (A), seizure precautions (B), and elevating the head (C) reduce complications in meningitis. Masks (D) are unnecessary, and negative pressure rooms (E) are for airborne diseases.
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The nurse is talking with the parent of a 22-month-old client. The parent states, 'I am worried about my child's thumb-sucking and its effects on tooth alignment.' Which of the following responses would be appropriate for the nurse to make? Select all that apply.
- A. Newer research demonstrates that thumb-sucking has little effect on a child's dentition.'
- B. Offer a security item such as a blanket to help your child self-soothe without thumb-sucking.'
- C. Provide positive reinforcement such as a sticker chart when your child avoids thumb-sucking.'
- D. The likelihood of needing braces because of thumb-sucking is significant when the behavior persists beyond 12 months of age.'
- E. The risk of malocclusion increases when thumb-sucking persists beyond the eruption of permanent teeth.'
Correct Answer: B, C, E
Rationale: Offering a security item (B), positive reinforcement (C), and noting malocclusion risk after permanent teeth erupt (E) are appropriate. Thumb-sucking has minimal effect before permanent teeth (A), and braces after 12 months (D) is exaggerated.
A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.
- A. Maintain short fingernails to minimize excoriating the skin
- B. Take a bath or shower in hot water to alleviate itching sensations
- C. Take prescribed cholestyramine 1 hour after other medications
- D. Use a moisturizing cream on unbroken skin daily
- E. Wear wool gloves and tight stockings to avoid scratching
Correct Answer: A, C, D
Rationale: Short fingernails (A), cholestyramine timing (C), and moisturizing cream (D) reduce itching and protect skin. Hot water (B) worsens itching, and wool gloves/tight stockings (E) may irritate skin.
Following an arteriogram, the nurse should give priority to:
- A. Allowing the client to rest
- B. Administering O2 via nasal mask
- C. Checking the ECG monitor
- D. Checking the pulses distal to the catheterization site
Correct Answer: D
Rationale: Checking distal pulses ensures adequate circulation post-arteriogram, as the procedure involves arterial puncture, which can lead to complications like hematoma or thrombosis.
The nurse has reinforced teaching with a client with newly diagnosed polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I should take an iron supplement daily.'
- B. I should increase my daily fluid intake.'
- C. I may require frequent phlebotomy.'
- D. I will take a low-dose aspirin daily.'
Correct Answer: A
Rationale: Iron supplements (A) can worsen polycythemia vera by increasing red blood cell production, requiring follow-up. Increased fluids (B), phlebotomy (C), and aspirin (D) are appropriate.
The nurse is caring for a client receiving chemotherapy. The client is prescribed filgrastim to improve the function of the immune system. Which finding does the nurse anticipate in response to the medication?
- A. Decrease in serum uric acid
- B. Increase in hemoglobin level
- C. Increase in neutrophil count
- D. Increase in platelet count
Correct Answer: C
Rationale: Filgrastim stimulates neutrophil production, so an increase in neutrophil count (C) is expected. It does not affect uric acid (A), hemoglobin (B), or platelets (D).