Nokea
The nurse is providing discharge instructions to the parents of a 6-month-old child with surgical repair for cryptorchidism. Which instruction would NOT be stressed?
- A. observe surgical site for bleeding
- B. enforce bed rest for 2-3 days
- C. palpate scrotum to check testicle location
- D. avoid strenuous activity for at least one month
Correct Answer: B
Rationale: Bed rest for 2-3 days is not typically required for cryptorchidism repair in infants, as recovery is quicker. Other instructions are critical for monitoring and safety.
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The nurse in an ambulatory care clinic is admitting a 27-year-old client with severe systemic lupus erythematosus (SLE). In assessing the client's health history, the nurse knows to question which of the following statements?
- A. I avoid being outside on sunny days.
- B. The medications I take make me bloated.
- C. My work schedule is down to four hours a day.
- D. I get an eye exam annually.
Correct Answer: D
Rationale: Annual eye exams may not be sufficient for SLE, as the condition and its treatments can cause frequent eye complications, requiring more regular monitoring.
A newborn is diagnosed with congenital syphilis. Classic signs of congenital syphilis are:
- A. Red papular rash, desquamation, white strawberry tongue
- B. Rhinitis, maculopapular rash, hepatosplenomegaly
- C. Red edematous cheeks, maculopapular rash on the trunk and extremities
- D. Epicanthal folds, low-set ears, protruding tongue
Correct Answer: B
Rationale: Congenital syphilis presents with rhinitis (‘snuffles'), maculopapular rash, and hepatosplenomegaly due to systemic infection.
The nurse is assessing a client with suspected dehydration. Which of the following findings would the nurse expect?
- A. Bradycardia and hypertension.
- B. Dry mucous membranes and tented skin.
- C. Clear, dilute urine.
- D. Increased respiratory rate.
Correct Answer: B
Rationale: dry mucous membranes and tented skin are signs of dehydration due to fluid loss
The client with a pacemaker should be taught to:
- A. Report ankle edema
- B. Check his blood pressure daily
- C. Refrain from using a microwave oven
- D. Monitor his pulse rate
Correct Answer: D
Rationale: Monitoring pulse rate ensures the pacemaker is functioning correctly and detects arrhythmias.
The nurse in the ER has received report of four clients en route to the emergency department. Which client should the nurse see first? A client with:
- A. Third-degree burns to the face and neck area, with singed nasal hairs
- B. Second-degree burns to each leg and thigh area, who is alert and oriented
- C. A chemical burn that has been removed and liberally flushed before admission
- D. An electrical burn entering and leaving on the same side of the body
Correct Answer: A
Rationale: Third-degree burns to the face and neck with singed nasal hairs suggest airway burns, a life-threatening condition requiring immediate airway assessment and management.