Nokea
The nurse is caring for a client with a history of Parkinson's disease. The nurse should expect the client to have:
- A. Tremors and rigidity
- B. Flaccid paralysis
- C. Spastic movements
- D. Ataxia
Correct Answer: A
Rationale: Parkinson's disease is characterized by tremors, rigidity, and bradykinesia due to dopamine deficiency in the basal ganglia.
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The client with a history of seizures is prescribed phenytoin (Dilantin). Which instruction should the nurse include in the teaching plan?
- A. Take the medication with milk to prevent stomach upset.'
- B. Avoid alcohol while taking this medication.'
- C. You can stop the medication if you have no seizures for a month.'
- D. Take an extra dose if you feel a seizure coming on.'
Correct Answer: B
Rationale: Alcohol can interact with phenytoin, increasing toxicity or reducing efficacy, so it should be avoided. Milk does not prevent GI upset, stopping medication requires physician guidance, and extra doses are dangerous.
A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information:
- A. He should monitor his sputum, stools, and urine for signs of bleeding.
- B. His daily diet should include a large amount of fluid.
- C. He should not be concerned about having to fly on a commuter airplane on a weekly basis.
- D. He should not worry about having children because this disease is passed on only by female carriers.
Correct Answer: B
Rationale: Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. Male and female clients with sickle cell disease can pass the trait on to their offspring. Therefore, this client should receive genetic counseling prior to having children.
The nurse is caring for a client with a history of a colostomy who is experiencing leakage around the stoma. The nurse should:
- A. Apply a larger appliance
- B. Clean the stoma with alcohol
- C. Check the skin barrier fit
- D. Irrigate the colostomy
Correct Answer: C
Rationale: Leakage around a colostomy stoma often indicates a poor skin barrier fit, requiring adjustment or resizing. Larger appliances, alcohol, and irrigation do not address the issue.
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish his supply every three months
- B. Take one tablet every 15 minutes if pain occurs
- C. Leave the medication in the brown bottle
- D. Crush the medication and take with water
Correct Answer: C
Rationale: Nitroglycerin should be stored in its original brown bottle to protect it from light and maintain potency. Replenishing every three months is not standard taking tablets every 15 minutes is incorrect (typically every 5 minutes up to 3 doses) and crushing is not appropriate.
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
- A. Examine the 4 year old first.
- B. Provide time for play and becoming acquainted.
- C. Have the mother leave the room with one child, and examine the other child privately.
- D. Examine painful areas first to get them 'over with.'
Correct Answer: B
Rationale: The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. Children generally cooperate best when their mother remains with them. Painful areas are best examined last and will permit maximum accuracy of assessment.