Nokea
The nurse is providing instruction to a client's family regarding home safety with thrombocytopenia. Which statement by the client's family indicates a need for further education?
- A. He should use an electric razor for shaving instead of a razor.
- B. We will use soft-bristled toothbrushes or tooth sponges for oral care.
- C. He can no longer take aspirin or aspirin-containing products for a headache.
- D. We should put rugs down on the hardwood floors to prevent his feet from getting cold.
Correct Answer: D
Rationale: Rugs pose a tripping hazard, increasing bleeding risk in thrombocytopenia. Other statements reflect safe practices to minimize bleeding.
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The nurse finds a client smoking marijuana in the hospital and tells her that no smoking or use of drugs is allowed in the facility. The client responds by shouting, 'What business is it of yours? Leave me alone!' Which of the following initial responses is the best for the nurse to use to defuse the situation?
- A. It's my business because I'm your nurse.'
- B. If you don't put that out immediately, I will call security.'
- C. You are violating the facility policies and the law!'
- D. I'm sorry, but I have to ask you again to put out your marijuana cigarette.'
Correct Answer: D
Rationale: A calm, polite request to stop (D) de-escalates the situation while reinforcing the rule. Other responses (A, B, C) are confrontational and likely to escalate the client's agitation.
A patient with hypothyroidism states that she takes Synthroid® 0.112 mg daily, but the pharmacy has issued the drug labeled in micrograms. How many micrograms of Synthroid® is equivalent to 0.112 mg? Record your answer using a whole number.
Correct Answer: 112
Rationale: To convert milligrams to micrograms, multiply by 1,000: 0.112 mg X 1,000 = 112 micrograms.
A child with achondroplasia will likely have which of the following physical characteristics?
- A. alopecia, failure to thrive, small face, recessed jaw
- B. enlarged hands and feet, skull expansion at fontanelle, enlarged tongue
- C. poor muscle tone, slanted eyes, single palmar crease
- D. dwarf stature, short fingers and toes, short proximal limbs
Correct Answer: D
Rationale: Achondroplasia causes dwarfism, short fingers/toes, and short proximal limbs due to impaired cartilage growth.
The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to:
- A. Avoid a high-fiber diet
- B. Continue to use ice packs
- C. Take a laxative daily to prevent constipation
- D. Use a sitz bath after each bowel movement
Correct Answer: D
Rationale: A sitz bath promotes healing and relieves pain after a hemorrhoidectomy by keeping the area clean and reducing inflammation.
An elderly female is admitted with a fractured right femoral neck. Which clinical manifestation would the nurse expect to find?
- A. Free movement of the right leg
- B. Abduction of the right leg
- C. Internal rotation of the right hip
- D. Shortening of the right leg
Correct Answer: D
Rationale: A femoral neck fracture typically causes shortening of the affected leg due to muscle contraction pulling the bone fragments together, along with external rotation and limited movement.