Nokea
The nurse is caring for a client with suspected acute rheumatic fever. Which of the following questions would be most important for the nurse to ask the client?
- A. Do you typically take all of your antibiotics when they are prescribed?
- B. Has anyone in your family had rheumatic fever?
- C. What has your temperature been over the past several days?
- D. Have you recently had a streptococcal throat infection?
Correct Answer: D
Rationale: Recent streptococcal infection (D) is the primary trigger for rheumatic fever, making it the most important question. Antibiotic compliance (A), family history (B), and fever (C) are relevant but less critical.
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The nurse is talking with a client who has type 1 diabetes mellitus and is receiving newly prescribed continuous subcutaneous insulin infusion therapy via an infusion pump. Which of the following statements by the client would indicate a correct understanding of the therapy?
- A. I will no longer need to test my blood glucose level throughout the day.
- B. I will no longer require an extra dose of insulin before my meals.
- C. My blood glucose levels should be more consistent throughout the day.
- D. The infusion set of my insulin pump should be changed daily.
Correct Answer: C
Rationale: Insulin pumps (C) provide steady insulin delivery, improving glucose stability. Glucose monitoring (A) and bolus doses (B) are still needed, and infusion sets are changed every 2-3 days, not daily (D).
The nurse is assisting in planning care for a client experiencing an acute attack of Ménière disease. Which action is a high priority to include in the plan of care?
- A. Initiate fall precautions
- B. Keep the emesis basin at bedside
- C. Provide a quiet environment
- D. Start IV fluids
Correct Answer: C
Rationale: A quiet environment (C) reduces sensory overload, a priority in Ménière disease attacks. Fall precautions (A), emesis basin (B), and IV fluids (D) are supportive but less critical.
The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply.
- A. Accepting a birthday gift of a gold bracelet from a client
- B. Offering to pray together if a client so wishes
- C. Sending a sympathy card to family after a client dies
- D. Soliciting a wealthy client to invest in a company
- E. Staying after work hours and drinking wine with a client
Correct Answer: A,D,E
Rationale: Accepting expensive gifts (A), soliciting investments (D), and socializing with alcohol (E) violate professional boundaries. Offering to pray (B) is acceptable if client-initiated, and a sympathy card (C) is appropriate.
A non-stress test has been ordered for a pregnant client with diabetes mellitus. Non-stress testing is a part of the diabetic's prenatal care because:
- A. Fetal movement is adversely affected by diabetes.
- B. Maternal insulin levels can have a negative effect on fetal energy.
- C. Diabetes can adversely affect development of placental vessels.
- D. Fetal lung maturity is most easily determined by non-stress testing.
Correct Answer: C
Rationale: Diabetes can impair placental vessel development, reducing oxygen and nutrient delivery to the fetus, necessitating non-stress testing to monitor fetal well-being. Fetal movement and lung maturity are assessed differently, and insulin's effect is indirect.
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
- A. Offer the baby sterile water between feedings of formula
- B. Apply an emollient to the baby's skin to prevent drying
- C. Wear a gown, gloves, and a mask while caring for the infant
- D. Place the baby on enteric isolation
Correct Answer: B
Rationale: Applying an emollient prevents skin drying, a common issue during phototherapy due to exposure to light.