Nokea
The nurse is teaching a client with a history of chronic sinusitis about self-care. The nurse should tell the client to:
- A. Use a humidifier
- B. Avoid hydration
- C. Use decongestants excessively
- D. Sleep with the head lowered
Correct Answer: A
Rationale: A humidifier keeps nasal passages moist, reducing irritation and promoting drainage in chronic sinusitis.
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A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:
- A. Dims the lights in her room
- B. Encourages her to breathe slowly and deeply
- C. Offers sips of warm liquids
- D. Places a large, soft pillow under her head
Correct Answer: A
Rationale: The discomfort of photophobia is alleviated by dimming the lights. Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis. It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.
The nurse is caring for a client with a history of a seizure disorder who is receiving Carbamazepine (Tegretol). The nurse should monitor the client for:
- A. Leukopenia
- B. Hypotension
- C. Hyperglycemia
- D. Weight gain
Correct Answer: A
Rationale: Carbamazepine can cause leukopenia, requiring monitoring of white blood cell counts. Hypotension, hyperglycemia, and weight gain are not primary side effects.
The nurse who is caring for a client with cancer notes a WBC of 500/mm3 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?
- A. Assess temperature every four hours because of risk for hypothermia.
- B. Instruct the client to avoid large crowds and people who are sick.
- C. Instruct in the use of a soft toothbrush.
- D. Assess for signs of bleeding.
Correct Answer: B
Rationale: A WBC of 500/mm3 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people (B) is critical. Hypothermia (A) is not a primary concern, soft toothbrush (C) prevents bleeding, and bleeding (D) is for thrombocytopenia.
The nurse teaches a pregnant client that a high-risk symptom occurring at any time during pregnancy that needs to be reported immediately to a healthcare provider is:
- A. Constipation
- B. Urinary frequency
- C. Breast tenderness
- D. Abdominal pain
Correct Answer: D
Rationale: Abdominal pain may be an indication of early spontaneous abortion, preterm delivery, or a placental abruption, requiring immediate medical attention.
A newborn weighed seven pounds at birth. At six months of age, the infant could be expected to weigh:
- A. 14 pounds
- B. 18 pounds
- C. 25 pounds
- D. 30 pounds
Correct Answer: A
Rationale: Infants typically double their birth weight by 6 months. A 7-pound newborn would weigh approximately 14 pounds at 6 months. The other weights are excessive or unrealistic.