Nokea
The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered
- A. Expected
- B. Rude
- C. Professional
- D. Enjoyable
Correct Answer: B
Rationale: Rude. Native Americans consider direct eye contact to be impolite or aggressive among strangers.
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A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding the most significant?
- A. Decreased level of consciousness (LOC)
- B. Elevated blood pressure
- C. Increased urine output
- D. Decreased heart rate
Correct Answer: C
Rationale: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
A newborn is to receive phototherapy for hyperbilirubinemia. Which nursing action is essential?
- A. Keep the infant NPO for two hours before the treatment.
- B. Ask the mother to stay away from the infant during the treatment.
- C. Monitor the client's pulse rate very carefully.
- D. Cover the baby's eyes during the treatment.
Correct Answer: D
Rationale: Covering the eyes protects the newborn's retinas from phototherapy light, a critical safety measure.
When teaching a mother about communicable diseases
When teaching a mother about communicable diseases, the nurse informs her that chickenpox is:
- A. Still communicable until all the vesicles have dried.
- B. Still communicable even when just dried scabs remain.
- C. No longer communicable after a high fever has subsided.
- D. Not communicable as long as the vesicles are intact and surrounded by a red areola.
Correct Answer: A
Rationale: Chickenpox is communicable until all vesicles have crusted over.
A client with mastoiditis has a left mastoidectomy with tympanoplasty. The nurse should observe the client for signs of damage to the sixth crania nerve, which include:
- A. Inability to chew
- B. Inability to look laterally
- C. Inability to swallow
- D. Loss of scalp sensation
Correct Answer: B
Rationale: The sixth cranial nerve (abducens) controls lateral eye movement, so damage would result in an inability to look laterally.
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler's position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position (30°–45° elevation) promotes lung expansion and reduces the risk of airway obstruction or aspiration post-bronchoscopy. Prone (B) limits respiratory assessment, neck extension (C) risks airway obstruction, and supine (D) is less optimal for breathing.