Nokea
The nurse is reviewing the medication history for a 24-year-old client in the fertility clinic. Which medication does the nurse understand to be a Category X medication in pregnancy?
- A. metformin
- B. amoxicillin
- C. gabapentin
- D. simvastatin
Correct Answer: D
Rationale: Simvastatin is Category X, contraindicated in pregnancy due to fetal harm. Others are safer (Categories B or C).
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The nurse is caring for a client diagnosed with syphilis. The client presents with a widespread, symmetric maculopapular rash on the palms and soles. The nurse understands that the client is in which stage of the infection?
- A. primary syphilis
- B. secondary syphilis
- C. early latent syphilis
- D. latent phase syphilis
Correct Answer: B
Rationale: A maculopapular rash on palms and soles is characteristic of secondary syphilis, following the primary chancre.
The nurse provides information to a client about performing a breast self-examination (BSE). The nurse determines that the client needs additional teaching if the client makes which statements? Select all that apply.
- A. The BSE must be done monthly.
- B. Lumps in my armpit area are normal.
- C. I can palpate my breasts with soapy water while showering.
- D. I should perform the examination on the day that I start my period.
- E. When I squeeze my nipples, I should expect to note some discharge.
- F. I should stand before a mirror and inspect each breast for anything unusual.
Correct Answer: B,D,E
Rationale: Any lumps in the armpit or nipple discharge are abnormal and require reporting to a healthcare provider. The BSE should be performed 2 to 3 days after menstruation ends, not on the first day, when breasts are tender. Monthly BSE, palpation with soapy water in the shower, and mirror inspection are correct techniques.
The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. What should the nurse do to appropriately test for asterixis?
- A. Examine the client's handwriting movements.
- B. Check the stool for clay-colored pigmentation.
- C. Ask the client to extend the wrist and the fingers.
- D. Check the serum bilirubin and liver enzyme levels.
Correct Answer: C
Rationale: Asterixis, or liver flap, is a rapid, nonrhythmic tremor in hepatic encephalopathy, tested by having the client extend the wrist and fingers. Handwriting is nonspecific, stool color is unrelated, and lab tests do not assess asterixis directly.
The home care nurse suspects that a client's spouse is experiencing caregiver strain. Which action should the nurse take to assess for this condition?
- A. Referring the family to a social services agency
- B. Gathering data from the caregiver and the client
- C. Waiting for the caregiver to talk about the stress
- D. Obtaining feedback from the client about the caregiver
Correct Answer: B
Rationale: Caregiver strain can occur when a client is significantly dependent on the caregiver for personal and health care needs. The nurse gathers data from the client and the caregiver to determine the caregiver's stressors and coping abilities and withholds making any referrals until the assessment is complete and the plan of care is in place. Because the nurse suspects caregiver strain, the nurse fulfills the duty to the client and family by approaching the family with the concern, gathering assessment data, and planning care. The nurse does not expect the client to assess the coping abilities of the caregiver because assessment is part of the nursing process and should not be delegated.
The nurse is teaching dietary modifications to the client with hypertension. The nurse should instruct the client to eat which snack foods?
- A. Raw carrots
- B. Celery stalks
- C. Frozen pizza
- D. Cheese and crackers
- E. Canned tomato soup
Correct Answer: A,B
Rationale: Sodium should be avoided by the client with hypertension. Fresh fruits and vegetables such as carrots and celery are naturally lower in sodium. Hypertensive clients are also advised to keep fat intake to less than 30% of their total calories as part of prudent heart living. Each of the incorrect options contains high amounts of sodium, and frozen pizza and cheese and crackers are also likely to be higher in fat.