Nokea
The nurse is teaching a client who has short-term memory loss how to use the call light. Which factor is least essential for the nurse to assess when teaching this client?
- A. Visual status
- B. Ambulatory difficulty
- C. Orientation to time, place, and person
- D. Understanding of the English language
Correct Answer: B
Rationale: Ambulatory difficulty is least relevant, as call light use relies on vision, orientation, and language comprehension, not mobility.
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The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse perform first?
- A. Clear the area of any hazards
- B. Place the child on its side
- C. Restrain the child
- D. Give the prescribed anticonvulsant
Correct Answer: B
Rationale: Place the child on its side. Protecting the airway is the top priority in a seizure to ensure a patent airway and oxygenation.
A 67-year-old man following a cardiac catheterization. Two hours after the procedure, the nurse checks the patient's insertion site in the antecubital space, and the patient complains that his hand is numb.
The nurse should
- A. change the position of his hand.
- B. check his grip strength in both hands.
- C. notify the physician.
- D. instruct the patient to exercise his fingers.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does the assessment answer validate what is going on? No. Determine the outcome of each answer choice. (1) assumes that numbness is related to positioning of hand, not circulatory changes (2) part of assessment, but doesn't indicate status of circulation (3) correct-absent or weak pulse or numbness could indicate problem with circulation, anticoagulants and vasodilators may be ordered (4) assumes that numbness is related to immobility of fingers, not circulatory changes
A client recovering from acute pancreatitis is started on solid food. Which of the following foods should be avoided?
- A. Vanilla custard
- B. Sponge cake
- C. Sliced peaches
- D. Cereal
Correct Answer: A
Rationale: Vanilla custard is high in fat, which can stimulate pancreatic enzyme release and worsen pancreatitis. Sponge cake, peaches, and cereal are lower in fat and safer.
The client is discharged from the unit with a prescription for Evista (raloxifene HCl). Which of the following is a side effect of this medication?
- A. Leg cramps
- B. Hot flashes
- C. Urinary frequency
- D. Cold extremities
Correct Answer: B
Rationale: Evista, used for osteoporosis, has an estrogen agonist effect, commonly causing hot flashes. It does not cause leg cramps , urinary frequency , or cold extremities .
Which information should be given to a client taking Dilantin (phenytoin)?
- A. Taking the medication with meals will increase its effectiveness
- B. The medication can cause sleep disturbances
- C. More frequent dental appointments will be needed for special gum care
- D. The medication decreases the effects of oral contraceptives
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, necessitating more frequent dental visits for gum care.