Nokea
The nurse is teaching a client with a new diagnosis of gout about allopurinol (Zyloprim). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any skin rash.
- C. Stop the medication if gout attacks cease.
- D. Avoid drinking plenty of water.
Correct Answer: B
Rationale: A skin rash may indicate a hypersensitivity reaction to allopurinol, requiring immediate reporting. Options A, C, and D are incorrect.
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A child in the waiting room who can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet.
The nurse identifies the child's chronological age to be
- A. 1 year old.
- B. 2 years old.
- C. 3 years old.
- D. 5 years old.
Correct Answer: C
Rationale: Strategy: Picture the child at each age. (1) unable to walk up and down stairs with hand held until 18 months (2) unable to jump until 30 months (3) correct-able to jump with both feet and stand on one foot momentarily at 30 months (4) behaviors are seen in younger child
The nurse is caring for a client who has been placed on a hypothermia blanket. What should the nurse include in the care plan?
- A. Take frequent vital signs and perform frequent skin assessments
- B. Leave the hypothermia blanket on until the client's temperature reaches 98.6°F
- C. Place the client directly on the blanket
- D. Apply iced alcohol sponges to the part of the client's trunk not in contact with the blanket
Correct Answer: A
Rationale: Frequent vital signs monitor for hypothermia or cardiovascular instability, and skin assessments prevent pressure injuries or cold burns. Direct blanket contact, prolonged use, or alcohol sponges risk skin damage or ineffective cooling.
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Which of the following responses by the nurse is the BEST?
- A. Do you hear voices talking to you?'
- B. Tell me why you are laughing so I can laugh too.'
- C. What is it that you find amusing?'
- D. I notice you're laughing.'
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
A client with a reactive depression has the greaTest chance of success in activities that require psychic and physical energy if the nurse schedules activities in the
- A. morning hours.
- B. middle of the day.
- C. afternoon hours.
- D. evening hours.
Correct Answer: A
Rationale: client with reactive depression has the highest level of physical and psychic energy in the morning
A preschool client's mother reports that the child has frequent bouts of gastroenteritis.
It would be MOST important for the nurse to ask which of the following questions?
- A. Are there other children in the family?'
- B. Does the child attend a day care center?'
- C. Does the child play with neighborhood children?'
- D. Is the child current on his immunizations?'
Correct Answer: B
Rationale: Strategy: Determine why the nurse would make the assessment and how it relates to gastroenteritis. (1) does not pose a problem or solution regarding gastroenteritis (2) correct-environments with increased numbers of children (day care) more likely to promote infections due to close living conditions and increased likelihood of disease transmission (3) possible source of infection, but not as likely as a day care center (4) does not pose a problem or solution regarding gastroenteritis