Nokea
The nurse is obtaining a health history from a Mexican American adult. The nurse should interpret the findings by understanding that Mexican American culture most highly values:
- A. Children
- B. Materialism
- C. Firstborn sons
- D. The elderly
Correct Answer: A
Rationale: Mexican American culture often places high value on children, emphasizing family and intergenerational bonds. Materialism, firstborn sons, and the elderly are valued but not as universally central.
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An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. The nurse should advise the mother to do which of the following?
- A. Notify the physician immediately to adjust the treatment plan.
- B. Confine the infant to one room in the apartment.
- C. Keep the infant in the splint at night, removing it during the day.
- D. Remove any unsafe items from the area in which the infant is mobile.
Correct Answer: D
Rationale: Removing unsafe items ensures the infant's safety while mobile in a splint, preventing further injury. The other options are unnecessary or impractical.
Which of the following demonstrates that the client needs further instruction after being taught about ciprofloxacin (Cipro)?
- A. I must drink 1,000 to 1,500mL of water a day
- B. I shouldn't take an antacid before taking the Cipro
- C. I should let the doctor know if I start vomiting from the Cipro
- D. I may get light-headed from the Cipro
Correct Answer: A
Rationale: Adequate hydration is important with ciprofloxacin, but 1,000–1,500 mL may be insufficient for adults, who typically need 2,000–3,000 mL daily to prevent crystalluria. Other statements are correct.
A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:
- A. Intermittent claudication.
- B. Dyspnea.
- C. Dependent edema.
- D. Crackles.
Correct Answer: C
Rationale: Dependent edema is a key sign of right-sided heart failure, as the heart fails to pump blood effectively, causing fluid backup in the extremities.
A client with a history of depression is prescribed duloxetine (Cymbalta). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Increased blood pressure.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Duloxetine can cause increased blood pressure, requiring immediate reporting to prevent cardiovascular complications.
Which of the following responses would be most appropriate for the nurse when comforting a primiparous client whose critically ill neonate delivered at 25 weeks dies while the mother is present?
- A. This is probably for the best because his organs were so immature.'
- B. You should try to get pregnant again soon to get over this loss.'
- C. You can stay with your baby as long as you want and say anything you want.'
- D. If you want me to, I can call the chaplain to stay with you.'
Correct Answer: C
Rationale: Allowing the mother to stay with her baby and express herself supports grieving and closure, which is most appropriate in this situation.