Nokea
The nurse is teaching a client with a new diagnosis of epilepsy about valproic acid (Depakote). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any bruising or bleeding.
- C. Stop the medication if seizures decrease.
- D. Avoid regular liver function Test s.
Correct Answer: B
Rationale: Valproic acid can cause thrombocytopenia; reporting bruising or bleeding is critical. Options A, C, and D are incorrect or unsafe.
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A child with celiac disease.
The nurse is instructing the parents of a child with celiac disease. The nurse knows that teaching has been effective when the parents make which of the following statements?
- A. My child's diet should include raw vegetables, fruits, and crackers.
- B. My child's diet should be high in carbohydrates, high in calories, and high in proteins.
- C. The only restriction in my child's diet should be breads and cereals.
- D. My child's diet should be high in calories, high in protein, and restrict foods containing rye, oats, wheat, and barley.
Correct Answer: D
Rationale: Strategy: 'Teaching has been effective' indicates you are looking for a correct statement. The topic of the question is unstated. (1) does not reflect appropriate dietary needs for this child (2) does not reflect appropriate dietary needs for this child (3) does not reflect appropriate dietary needs for this child (4) correct-celiac disease is characterized by an intolerance for gluten; foods containing rye, oats, wheat, and barley should be restricted
A client with a twenty-five-year history of alcohol abuse is seen in the outpatient clinic for treatment of chronic cirrhosis.
Which of the following symptoms would suggest to the nurse that the client is in the early stages of hepatic encephalopathy?
- A. The patient's abdomen is distended with a protruding umbilicus.
- B. The patient has difficulty describing what he does at work.
- C. The patient's respirations are 32, and he appears to be drowsy.
- D. The patient's upper extremities are adducted, and his lower extremities are internally rotated.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to hepatic encephalopathy. (1) ascites is symptom of cirrhosis (2) correct-impaired thought processes is early symptom (3) hyperventilation and stupor is late symptom (4) decerebrate/decorticate posturing late symptom
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions is the PRIORITY?
- A. Encourage the client to use the incentive spirometer.
- B. Administer pain medication as needed.
- C. Position the client with the legs abducted.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Positioning with legs abducted prevents hip dislocation, a critical complication post-hip replacement. Options A, B, and D are important but secondary: incentive spirometry prevents pneumonia, pain management supports recovery, and dressing checks monitor bleeding.
The nurse is caring for a client with a history of hypertension who is receiving hydralazine (Apresoline) 25 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Heart rate of 100 bpm
- C. Chest pain and shortness of breath
- D. Mild headache
Correct Answer: C
Rationale: Chest pain and shortness of breath suggest angina or lupus-like syndrome, serious hydralazine side effects. Options A, B, and D are less urgent: BP is normal, tachycardia is mild, and headache is common.
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: The resistant bacteria remain alive for up to 3 days after the client dies. Therefore, contact precautions must still be implemented.