Nokea
The nurse is preparing to assess a client admitted with a diagnosis of trigeminal neuralgia (tic douloureux). On review of the client's record, which symptom should the nurse expect the client is experiencing?
- A. Bilateral pain in the area of the sixth cranial nerve
- B. Unilateral pain in the area of the sixth cranial nerve
- C. Abrupt onset of pain in the area of the fifth cranial nerve
- D. Chronic, intermittent pain in the area of the seventh cranial nerve
Correct Answer: C
Rationale: Trigeminal neuralgia is a chronic syndrome characterized by an abrupt onset of pain. It involves one or more divisions of the trigeminal nerve (cranial nerve V). The remaining options are incorrect.
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The nurse is caring for a client with a history of peripheral arterial disease. Which of the following interventions should be included in the plan of care?
- A. Elevate the legs above heart level.
- B. Apply heating pads to the affected limbs.
- C. Encourage walking to tolerance.
- D. Restrict fluid intake.
Correct Answer: C
Rationale: Walking to tolerance improves collateral circulation in peripheral arterial disease.
A client with chronic kidney disease is on a low-potassium diet. Which food should the nurse advise the client to avoid?
- A. Apples.
- B. Bananas.
- C. Cauliflower.
- D. White bread.
Correct Answer: B
Rationale: Bananas are high in potassium, which must be limited in chronic kidney disease to prevent hyperkalemia.
A child diagnosed with tinea is being treated with griseofulvin (Grifulvin V). Which of the following instructions should the nurse give to the parents?
- A. Give the medication before a meal
- B. Have the child avoid intense sunlight
- C. Give the medication for 10 days
- D. Encourage increased fluid intake
Correct Answer: B
Rationale: Griseofulvin increases photosensitivity, so avoiding intense sunlight is critical. It is typically taken with food, requires weeks of treatment, and fluid intake is not specifically needed.
A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When asking this client to complete a task, what techniques should the nurse use to communicate most effectively with him?
- A. Obtain eye contact before speaking, use simple language, and have him repeat what was said. Praise him if he completes the task.
- B. Fully explain to the client the actions required of him, offer verbal praise and a food reward for task completion.
- C. Explain to the client what he is to do, the consequences if he does not comply, and follow through with praise or consequences as appropriate.
- D. Demonstrate to the client what he is to do, have him imitate the nurse's actions, and give a food reward if he completes the task.
Correct Answer: A
Rationale: Clear, simple instructions with eye contact and repetition enhance communication for a child with ADHD, and praise reinforces positive behavior.
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse should expect to observe which of the following symptoms?
- A. Positive Babinski reflex.
- B. High-pitched cry.
- C. Hypothermia.
- D. Kernig's sign.
Correct Answer: B
Rationale: A high-pitched cry is a common symptom of bacterial meningitis in infants, indicating neurological irritation.