Nokea
The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is
- A. Eat a balanced diet for your age.
- B. Increase your intake of protein and Vitamin A.
- C. Decrease fatty foods from your diet.
- D. Do not use caffeine in any form, including chocolate.
Correct Answer: A
Rationale: Eat a balanced diet for your age. There are no recommended additions and subtractions from the diet for acne management.
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A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: The resistant bacteria remain alive for up to 3 days after the client dies. Therefore, contact precautions must still be implemented.
A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?
- A. Double vision and visual halos
- B. Extremity tingling and numbness
- C. Confusion and lightheadedness
- D. Sensitivity of sunlight
Correct Answer: B
Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.
A client with suspected Addison's disease is scheduled for a rapid corticotrophin stimulation test. Which of the following will the nurse include in her teaching?
- A. The need to limit fluid intake
- B. The need for periodic blood samples
- C. The need for collection of a 24-hour urine
- D. The need for frequent IV injections
Correct Answer: B
Rationale: The rapid corticotrophin stimulation test requires periodic blood samples to measure cortisol levels before and after ACTH administration.
Which of the following interventions is appropriate when caring for a client who has lost function of cranial nerve $\mathrm{V}$ on the left side?
- A. Helping the client select foods that are easy to swallow
- B. Speaking to the client on his right side
- C. Applying an eye patch to the left eye
- D. Speaking to the client on his left side
Correct Answer: C
Rationale: Cranial nerve V (trigeminal) loss may impair corneal sensation, increasing risk of eye injury; an eye patch protects the left eye. Swallowing and hearing are unrelated.
An HIV-positive infant to receive an oral polio immunization.
Which of the following nursing actions is MOST appropriate?
- A. Wear gloves and a gown when administering the immunization.
- B. Administer the immunization as the infant is being discharged.
- C. Call the physician and discuss the rationale for the immunization.
- D. Administer the medication in the same manner as you would to any other infant.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the identified problem of the compromised immune system (2) does not address the identified problem of the compromised immune system (3) correct-polio vaccine contains live virus and should not be given to children who are immunocompromised (4) does not address the identified problem of the compromised immune system