Nokea
The nurse is teaching a client with a history of osteoporosis about fall prevention. The nurse should tell the client to:
- A. Remove clutter from walkways
- B. Use high-heeled shoes
- C. Avoid handrails
- D. Keep rooms dimly lit
Correct Answer: A
Rationale: Removing clutter prevents falls in osteoporosis, reducing fracture risk.
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A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?
- A. Hyperactivity in the evening hours
- B. Weight gain
- C. Paresthesia of hands and feet
- D. Diarrhea stools
Correct Answer: C
Rationale: Paresthesia of hands and feet indicates B12 deficiency due to noncompliance with injections, as B12 is needed for nerve function. Hyperactivity (A), weight gain (B), and diarrhea (D) are not specific to B12 deficiency.
The pediatrician has diagnosed tinea capitis in an 8-year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
- A. Administer oral griseofulvin on an empty stomach for best results.
- B. Discontinue drug therapy if food tastes funny.
- C. May discontinue medication when the child experiences symptomatic relief.
- D. Observe for headaches, dizziness, and anorexia.
Correct Answer: D
Rationale: Giving the drug with or after meals may allay gastrointestinal discomfort. Giving the drug with a fatty meal (ice cream or milk) increases absorption rate. Griseofulvin may alter taste sensations and thereby decrease the appetite. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. The child may experience symptomatic relief after 48-96 hours of therapy. It is important to stress continuing the drug therapy to prevent relapse (usually about 6 weeks). The incidence of side effects is low; however, headaches are common. Nausea, vomiting, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician.
A newborn girl's father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:
- A. Mild hypotonia is expected in the upper extremities.
- B. Purposeless, uncoordinated movements of the arms are indicative of neurological dysfunction.
- C. Function progresses in a head-to-toe, proximal-distal fashion.
- D. Asymmetrical movement of the extremities is not unusual and will disappear with maturation of the central nervous system.
Correct Answer: C
Rationale: Term neonates are predominantly in a flexed position with strong active muscle tone that increases. Newborns are slightly hypertonic. Neonatal movements may be jerky and uncoordinated as the neonate works against gravity in contrast to the buoyancy of the amniotic fluid. Jerky movements must be differentiated from the tremors of hypoglycemia, hypocalcemia, and neurological dysfunction. Growth of the newborn progresses in a cephalocaudal, proximal-distal fashion. Knowledge regarding infant development may facilitate parental involvement and infant stimulation. Asymmetrical movements of the extremities are indicative of neurological dysfunction.
The nurse is caring for a client with a diagnosis of postpartum depression. Which intervention is most appropriate?
- A. Refer to a psychiatrist
- B. Administer antibiotics
- C. Monitor fetal heart tones
- D. Administer tocolytics
Correct Answer: A
Rationale: Postpartum depression requires mental health intervention such as referral to a psychiatrist for therapy or medication. Antibiotics fetal monitoring and tocolytics are irrelevant to this condition.
The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:
- A. Avoid air travel
- B. Sleep on the affected side
- C. Resume heavy lifting
- D. Restrict fluid intake
Correct Answer: A
Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.