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The nurse is reinforcing discharge teaching with the parent of a 6-year-old client who had a tonsillectomy 4 hours ago. The nurse should reinforce that it would be a priority to notify the health care provider if the client experiences
- A. Ear pain
- B. Foul-smelling breath
- C. Frequent swallowing
- D. Low-grade fever
Correct Answer: C
Rationale: Frequent swallowing (C) may indicate bleeding, a serious post-tonsillectomy complication requiring immediate reporting. Ear pain (A), bad breath (B), and low-grade fever (D) are common and less urgent.
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The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?
- A. Did you hear that voice? It told me to kill my parent.
- B. I need to get rid of the bugs that are crawling under my skin.
- C. The song on the radio is a message sent to me in secret code.
- D. I will not drink the tap water. The aliens are trying to poison me.
Correct Answer: C
Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (C). Auditory hallucinations (A) involve hearing voices, not reference. Tactile hallucinations (B) involve false sensations, and persecutory delusions (D) involve belief in harm without reference to neutral stimuli.
The nurse is caring for assigned clients. The nurse should first check the
- A. 3-year-old client who has fever and right hip pain and is refusing to move the right leg
- B. 7-year-old client who has sinus congestion and a productive cough
- C. 10-year-old client who has an active nosebleed and is applying pressure to the nose
- D. 12-year-old client who has fever, urinary frequency, and dysuria
Correct Answer: A
Rationale: A 3-year-old with fever, hip pain, and refusal to move the leg (A) may indicate a serious condition like septic arthritis or osteomyelitis, requiring immediate assessment to prevent joint damage or systemic infection. Sinus congestion (B) and urinary symptoms (D) are less urgent, and the nosebleed (C) is being managed with pressure, making them lower priorities.
A client is diagnosed as having secondary Cushing's syndrome. The nurse knows that the client has most likely been taking which medication?
- A. Estrogen
- B. Penicillin
- C. Lovastatin
- D. Prednisone
Correct Answer: D
Rationale: Secondary Cushing's syndrome is often caused by long-term prednisone use, a corticosteroid mimicking cortisol excess. Estrogen, penicillin, or lovastatin do not cause this condition.
A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity?
- A. Serum potassium
- B. Protein intake
- C. Lactose tolerance
- D. Serum albumin
Correct Answer: D
Rationale: Serum albumin. When highly protein-bound drugs are administered to patients with low serum albumin (protein) levels, excess free (unbound) drug can cause exaggerated and dangerous effects.
After a recent outbreak of varicella in an elementary school, the practical nurse is assisting with the development of an informative letter to parents. Which of the following instructions are appropriate to include? Select all that apply.
- A. Apply calamine lotion to soothe lesions
- B. Clip your child’s fingernails short
- C. Ensure that your child’s vaccinations are up to date
- D. Keep your child home until lesions have crusted
- E. Place mittens on your child’s hands when sleeping
Correct Answer: A,B,C,D,E
Rationale: Calamine lotion (A) relieves itching, short nails (B) and mittens (E) prevent scratching, vaccinations (C) protect against future infection, and isolation until crusted (D) prevents transmission. All are appropriate.