Nokea
The nurse is talking with a client with unilateral facial paralysis. Which of the following statements by the client would require follow-up? Select all that apply.
- A. I may chew food on either side of my mouth because it does not hurt
- B. I need to use my fingers to close my eyelid after instilling eye drops
- C. I should prepare meals that include soft, high-calorie foods
- D. I will place tape on my affected eyelid before I go to sleep
- E. I will put ice on the affected side of my face when it hurts
Correct Answer: A,E
Rationale: Chewing on the affected side risks injury due to impaired sensation, and ice may worsen symptoms in conditions like Bell’s palsy. Closing the eyelid, taping at night, and soft foods are appropriate for facial paralysis management.
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The nurse enters a client’s room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene?
- A. UAP applies the anti-embolism stockings while maintaining the client in supine position
- B. UAP carefully smoothes out any wrinkles over the length of the stockings
- C. UAP checks that the toe opening of the stockings is located on the plantar side of the foot
- D. UAP rolls down and folds over the excess material at the top of the stockings
Correct Answer: D
Rationale: Rolling and folding the stockings creates pressure points, risking skin breakdown and poor circulation. Supine application and correct toe opening placement are appropriate.
The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
- A. Widening pulse pressure
- B. Pleural friction rub
- C. Distended neck veins
- D. Bradycardia
Correct Answer: C
Rationale: Distended neck veins. Cardiac tamponade causes venous congestion, leading to distended neck veins.
The nurse is reinforcing discharge instructions for a client with degenerative joint disease and a new prescription for naproxen. What instructions regarding this drug does the nurse include? Select all that apply.
- A. Avoid driving while taking this medicine
- B. Change positions slowly
- C. Discontinue immediately if suicidal thoughts occur
- D. Notify the health care provider of tarry stools
- E. Take the medicine with food
Correct Answer: D,E
Rationale: Tarry stools indicate potential GI bleeding, a serious naproxen side effect, and taking with food reduces GI irritation. Driving, position changes, and suicidal thoughts are not primary concerns with naproxen.
The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply.
- A. Advising measles vaccination for susceptible family members
- B. Applying calamine lotion to reduce itching
- C. Placing a tracheostomy tray at the bedside
- D. Placing the client in a negative pressure isolation room
- E. Using an N95 respirator mask during client contact
Correct Answer: A,D
Rationale: Measles is highly contagious, requiring negative pressure isolation to prevent airborne spread and vaccination for susceptible contacts to prevent outbreaks. Calamine is for skin conditions like chickenpox, tracheostomy is not indicated, and N95 masks are for tuberculosis, not measles (droplet precautions).
The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking Eskalith (lithium carbonate). Which of the following snacks would be best for the client?
- A. Potato chips
- B. Diet cola
- C. An apple
- D. A milkshake
Correct Answer: C
Rationale: Lithium carbonate can cause sodium depletion, and high-sodium snacks like potato chips should be avoided to prevent toxicity. Diet cola lacks nutritional value and may contain caffeine, which can exacerbate mania. An apple is a healthy, low-sodium snack that supports hydration and nutrition. A milkshake may be high in sugar or fat, which is less ideal.