Nokea
The nurse is caring for an older adult in his home. Which of the following factors increase the client's risk for falls? Select all that apply.
- A. The client is 78 years old.
- B. The home is a one-story home.
- C. There are several scatter rugs on the hardwood floors.
- D. The client's wife does all of the housework.
- E. There are handrails in the bathroom.
- F. There are several plants in the living room.
Correct Answer: A,C,F
Rationale: Age over 65, scatter rugs, and obstacles like plants increase fall risk. A one-story home, handrails, and the wife's housework reduce risk.
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The nurse is caring for a client who is postoperative day 1 after a laparoscopic cholecystectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Right shoulder pain.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-cholecystectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain is normal, shoulder pain is from referred diaphragmatic irritation, and urine output 40 mL/hour is adequate.
A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
- A. Gestational age assessment suggested growth retardation
- B. Meconium was cleared from the airway at delivery
- C. Phototherapy was used to treat Rh incompatibility
- D. The infant received mechanical ventilation for 2 weeks
Correct Answer: D
Rationale: The infant received mechanical ventilation for 2 weeks. Bronchopulmonary dysplasia is often caused by prolonged mechanical ventilation.
The nurse is providing care to a newly hospitalized adolescent. What is the major threat experienced by the hospitalized adolescent?
- A. Pain management
- B. Restricted physical activity
- C. Altered body image
- D. Separation from family
Correct Answer: C
Rationale: The hospitalized adolescent may see each of these as a threat, but the major threat that they feel when hospitalized is the fear of altered body image, because of the emphasis on physical appearance during this developmental stage.
During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:
- A. Silver sulfadiazine (Silvadene)
- B. Poviodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Silver nitrate
Correct Answer: C
Rationale: Mafenide acetate (Sulfamylon) is particularly effective against Pseudomonas infections due to its broad-spectrum antibacterial activity and ability to penetrate eschar. Silver sulfadiazine is less effective against Pseudomonas, and povidone-iodine and silver nitrate are not the primary choices for Pseudomonas infections. Answers A, B, and D are incorrect because they are less effective for this specific infection.
The nurse is caring for a child with celiac disease. The nurse's discharge teaching plan should include:
- A. Dietary instructions and a list of foods to be avoided
- B. Hand-washing instructions to prevent disease transmission
- C. Instructions to continue antibiotics for 1 week
- D. Explaining that one attack confers immunity
Correct Answer: A
Rationale: Celiac disease requires a gluten-free diet, so dietary instructions and a list of foods to avoid are essential, making A correct. Hand-washing , antibiotics , and immunity are not relevant to celiac disease management.