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 in an outpatient clinic is caring for a client at 34 weeks gestation. The client is taking ferrous sulfate for anemia and reports constipation. Which of the following recommendations should the nurse reinforce for this client? Select all that apply.
- A. Decreased daily intake of dairy products
- B. Increased intake of fruits and vegetables
- C. Moderate-intensity exercise regularly
- D. One stimulant laxative daily for a week
- E. Two cups of hot coffee each morning
Correct Answer: B,C
Rationale: Fruits and vegetables provide fiber, and exercise promotes bowel motility, relieving constipation. Dairy may worsen constipation, stimulant laxatives are not first-line in pregnancy, and coffee is not a primary solution.
A client at 20 weeks gestation reports 'running to the bathroom all the time,' pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client?
- A. Are you having any pain in your lower back or flank area?
- B. Do you wipe from front to back after urinating?
- C. Have you found that you urinate more frequently since becoming pregnant?
- D. Have you had a urinary tract infection in the past?
Correct Answer: A
Rationale: Back or flank pain suggests pyelonephritis, a serious complication of UTI in pregnancy, requiring urgent evaluation. Hygiene, frequency, and history are relevant but less critical than assessing for systemic infection.
The nurse is assisting with the care of a newborn during circumcision. Which intervention is appropriate?
- A. Anticipate the use of clean technique during the circumcision
- B. Apply a snug-fitting diaper following the procedure
- C. Offer a bottle during the procedure
- D. Wrap the newborn’s upper body in a blanket for the circumcision
Correct Answer: D
Rationale: Wrapping the upper body keeps the newborn warm and secure during circumcision. Sterile technique is required, snug diapers risk irritation, and feeding during the procedure poses a choking risk.
The nurse is reinforcing teaching for a client who is a college athlete and was recently diagnosed with moderate persistent asthma. The nurse should instruct the client to avoid
- A. penicillin antibiotics
- B. talc-containing products
- C. strenuous physical activity
- D. secondhand smoke exposure
Correct Answer: D
Rationale: Secondhand smoke is a known asthma trigger, exacerbating symptoms. Penicillin, talc, and strenuous activity are not primary asthma triggers, though activity may require premedication with bronchodilators.
A father brings his 17-year-old son to a walk-in clinic. The client reports a sudden severe headache. He has a temperature of 104°F and a purple rash. What is the best action for the nurse at this time?
- A. Prepare for a throat culture
- B. Schedule him for an appointment later in the day
- C. Isolate and alert the physician immediately
- D. Obtain a urine specimen
Correct Answer: C
Rationale: Symptoms suggest meningococcal meningitis, a medical emergency requiring isolation and immediate physician notification.