Nokea
The nurse is instructing a client on how to care for skin that has become dry after radiation therapy. Which of the following statements by the client indicates that the client understands the teaching?
- A. I should take antihistamines to decrease the itching I am experiencing.'
- B. It is safe to apply a nonperfumed lotion to my skin.'
- C. A heating pad, set on the lowest setting, will help decrease my discomfort.'
- D. I can apply an over-the-counter cortisone ointment to relieve the dryness.'
Correct Answer: B
Rationale: Nonperfumed lotion is safe for dry, irradiated skin, as it moisturizes without causing irritation or allergic reactions.
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The nurse caring for a client who recently received an epidural anesthesia for a vaginal delivery suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma?
- A. Changes in vital signs
- B. Signs of vaginal bruising
- C. Client reporting a tearing sensation
- D. Client reporting intense vaginal pressure
Correct Answer: A
Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Vaginal bruising may be present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a hematoma. Because the client received anesthesia, she would not feel pain or pressure.
The nurse is caring for a client with a spinal cord injury at C5. Which complication should the nurse monitor for?
- A. Respiratory distress
- B. Urinary retention
- C. Pressure ulcers
- D. All of the above
Correct Answer: D
Rationale: A C5 spinal cord injury can cause respiratory distress (diaphragm impairment), urinary retention (loss of bladder control), and pressure ulcers (immobility), requiring comprehensive monitoring.
One of the primary purposes of a formal medication reconciliation is to:
- A. Prevent polypharmacy
- B. Conserve financial resources
- C. Prevent interactions
- D. Prevent allergies
Correct Answer: C
Rationale: Medication reconciliation compares current and previous medication lists to identify and prevent potential drug interactions, ensuring safe prescribing.
A client with a history of cirrhosis is admitted with ascites. The nurse should include which of the following in the plan of care?
- A. Administer spironolactone as prescribed.
- B. Restrict sodium intake.
- C. Encourage a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A, B
Rationale: Spironolactone and sodium restriction reduce fluid retention in ascites.
A 13-year-old male was kidnapped and held for ransom by two criminals. His parents asked to have him admitted to the adolescent psychiatric unit. He is sleep-deprived, filthy, alternating between sobbing and making threats to kill his captors, and then asks to go to sleep. What is the best initial plan for this client?
- A. Encourage him to talk with the Federal Bureau of Investigation (FBI) about the crime details.
- B. Develop trust and allow him to talk about his memories and feelings.
- C. Help him and his parents prepare for the future trial.
- D. Discourage him from making threats toward his captors.
Correct Answer: B
Rationale: Building trust and allowing the client to express feelings addresses immediate emotional needs and trauma, prioritizing mental health support.