Nokea
The nurse is caring for a client with a history of depression.
- A. Which client statement indicates a positive response to antidepressant therapy?
- B. I feel like my old self again.'
- C. I don’t need to take the medication anymore.'
- D. I’m sleeping more than usual.'
- E. I still feel sad most of the time.'
Correct Answer: A
Rationale: Feeling like their old self indicates improved mood and function, a positive response to antidepressants. Stopping medication prematurely, excessive sleep, or persistent sadness suggest inadequate response or side effects.
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The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?
- A. I'm going to try feeding my baby some rice cereal.'
- B. When he wakes at night for a bottle, I feed him.'
- C. I dip his pacifier in honey so he'll take it.'
- D. I keep formula in the refrigerator for 24 hours.'
Correct Answer: C
Rationale: I dip his pacifier in honey so he'll take it.' Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.
A client has returned from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include
- A. the time and circumstances under which the rash was noted.
- B. the explanation given to the client and family of the reason for the rash.
- C. notation on an allergy list and notification of the doctor.
- D. the need for application of corticosteroid cream to decrease inflammation.
Correct Answer: C
Rationale: suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies
The nurse is caring for a client with a history of polycystic kidney disease.
- A. Which symptom is expected in a client with polycystic kidney disease?
- B. Chest pain and dyspnea.
- C. Flank pain and hematuria.
- D. Weight loss and fever.
- E. Numbness in the extremities.
Correct Answer: B
Rationale: Flank pain and hematuria are common in polycystic kidney disease due to cyst pressure and rupture. Chest pain, weight loss, and numbness are unrelated.
A baby is delivered following a pregnancy complicated by gestational diabetes. What should the nurse observe the baby for?
- A. Infection
- B. Hyperglycemia
- C. Acidosis
- D. Hypoglycemia
Correct Answer: D
Rationale: Infants of mothers with gestational diabetes are at risk for hypoglycemia due to high fetal insulin levels from maternal hyperglycemia, requiring close monitoring.
A toddler admitted with an elevated blood lead level is to be treated with intramuscular (IM) injections of calcium disodium edetate (Calcium EDTA) and dimercaprol (BAL).
Which of the following nursing actions should have the highest priority?
- A. Keep a tongue blade at the bedside.
- B. Encourage the child to participate in play therapy.
- C. Apply cool soaks to the injection site.
- D. Rotate the injection sites.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no longer used for seizures, but it is important to have seizure precautions and emergency respiratory equipment available (2) important to implement, but is not a priority (3) contains incorrect information (4) correct-highest priority is to prevent tissue damage and promote tissue absorption of the medicine, accomplished through rotation of the injection sites