Nokea
The nurse is caring for a client with a history of a stroke who has expressive aphasia. The nurse should:
- A. Speak loudly to the client
- B. Use simple, short sentences
- C. Provide a whiteboard for communication
- D. Limit all verbal interactions
Correct Answer: C
Rationale: Expressive aphasia impairs speech production. A whiteboard facilitates communication. Simple sentences help, but writing aids are critical, and loud speech or limiting interaction is unhelpful.
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The clinic nurse is teaching a co-worker regarding medication administration. The nurse is aware that which of the following medications are category X medications and should not be taken by the client during pregnancy?
- A. Menocycline
- B. Tazorac
- C. Devonex
- D. Levothyroxine
- E. Cefozolin
Correct Answer: A, B
Rationale: Category X medications, like minocycline (A) and tazarotene (Tazorac, B), are contraindicated in pregnancy due to fetal harm. Calcipotriene (Devonex, C), levothyroxine (D), and cefazolin (E) are safer (categories B or C).
The nurse is caring for a client with a history of sickle cell anemia. Which intervention is most important during a sickle cell crisis?
- A. Administer oxygen
- B. Apply cold packs to joints
- C. Encourage bed rest
- D. Administer antibiotics
Correct Answer: A
Rationale: Sickle cell crisis causes vaso-occlusion, reducing tissue oxygenation. Administering oxygen is the priority to prevent hypoxia. Cold packs worsen vasoconstriction, rest is secondary, and antibiotics are for infections.
A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:
- A. Protect the child from infection
- B. Provide the child with privacy
- C. Protect the family from curious visitors
- D. Isolate the child from other clients and the nursing staff
Correct Answer: A
Rationale: The child no longer has normal white blood cells and is extremely susceptible to infection, necessitating protective isolation.
A client with a history of epilepsy is admitted with status epilepticus. The nurse should give priority to:
- A. Administering oxygen
- B. Protecting the airway
- C. Administering anticonvulsants
- D. Monitoring blood pressure
Correct Answer: B
Rationale: In status epilepticus, prolonged seizures can obstruct the airway, so protecting the airway is the priority to ensure oxygenation and prevent asphyxia.
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
- A. Clean the sutured laceration twice a day with povidone-iodine (Betadine)
- B. Remove his scalp sutures after 5 days
- C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
- D. Take meperidine 50 mg po q4-6h prn for headache
Correct Answer: C
Rationale: Confusion, nausea, or vomiting may indicate increasing intracranial pressure from a possible head injury, requiring immediate evaluation.