Nokea
The nurse is screening clients for those at risk for developing oral candidiasis. The nurse should recognize the client at highest risk for developing oral candidiasis is a client who
- A. has asthma and uses an albuterol nebulizer once a week
- B. has dental braces and consumes several high sugar beverages daily
- C. is HIV positive and has been receiving antibiotics daily for the past 3 months
- D. has a decreased serum albumin level after consuming a vegan diet for the past 6 months
Correct Answer: C
Rationale: An HIV-positive client on long-term antibiotics is at highest risk for oral candidiasis due to immunosuppression and microbial imbalance. Albuterol use , sugary drinks , and low albumin are less significant risk factors.
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A client with Alzheimer disease is admitted to the hospital. The client's adult child says to the nurse, 'I really want to continue caring for my mother at home, but she has become agitated and restless at night. I am awake most of the night, feel exhausted, and do not know what to do.' What is the best response by the nurse?
- A. Do not let your mother take naps in the afternoon.'
- B. Our social worker can discuss supportive options with you.'
- C. We can ask the health care provider for medication that will help your mother sleep.'
- D. Your mother should be cared for in a skilled nursing facility.'
Correct Answer: B
Rationale: Referring to a social worker provides access to resources like respite care or home support, addressing the caregiver's exhaustion. Limiting naps or medication may help but are narrow, and suggesting a facility dismisses the caregiver's wishes.
The nurse has attended a staff education program about narcissistic personality disorder (NPD). The nurse should understand that clients with NPD
- A. experience a fear of abandonment and have a fragile self-esteem
- B. may require medication to manage hallucinations
- C. demonstrate magical thinking and feelings of depersonalization
- D. experience episodes of acute anxiety
Correct Answer: A
Rationale: Clients with NPD typically have a fragile self-esteem masked by grandiosity and may fear abandonment . Hallucinations are not characteristic, magical thinking aligns more with schizotypal personality disorder, and acute anxiety is less specific.
Vital signs
Temperature 100.9 F (38.3 C)
Blood pressure 125/75 mm Hg
Heart rate 109/min
Respirations 15/min
SpO2 100%
The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer?
- A. Acetaminophen PO PRN for fever
- B. Clindamycin IV every 8 hours
- C. Lactated Ringer IV bolus once
- D. Methylergonovine PO every 4 hours
Correct Answer: B
Rationale: Postpartum endometritis requires prompt antibiotic treatment, so clindamycin IV is the priority to address the infection. Acetaminophen , fluids , and methylergonovine are supportive or unrelated.
The nurse is discussing mammogram screening with a family. No one in the family has had a mammogram. The mother is 52, there are four daughters, ages 10, 15, 21, and 34, and the grandmother is 75. Which of the following women should receive a mammogram? Select all that apply.
- A. The 10-year old daughter
- B. The 15-year old daughter
- C. The 21-year old daughter
- D. The 34-year old daughter
- E. The 52-year old mother
- F. The 75-year-old grandmother
Correct Answer: D,E,F
Rationale: Women aged 40 and older, or earlier with risk factors, should have mammograms. The 34-year-old, 52-year-old, and 75-year-old women meet screening age criteria.
The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply.
- A. Encourage the parents to leave the child's favorite stuffed animal
- B. Establish a daily schedule similar to the child's home routine
- C. Give the child time to calm down alone when visibly upset
- D. Provide frequent opportunities for play and activity
- E. Remove visual reminders of the parents from the room
Correct Answer: A,B,D
Rationale: To manage separation anxiety: a stuffed animal provides comfort, a familiar schedule offers stability, and play distracts and engages. Isolating the child may worsen anxiety, and removing parental reminders could increase distress.