Nokea
The nurse is teaching a client with a new diagnosis of osteoporosis about dietary management. Which of the following foods should the nurse recommend?
- A. Yogurt.
- B. Bananas.
- C. White bread.
- D. Red meat.
Correct Answer: A
Rationale: Yogurt is high in calcium, essential for bone health in osteoporosis.
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A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Nausea.
- B. Gingival hyperplasia.
- C. Rash.
- D. Drowsiness.
Correct Answer: C
Rationale: A rash may indicate a serious hypersensitivity reaction to phenytoin, such as Stevens-Johnson syndrome, requiring immediate reporting.
A client with a diagnosis of bipolar disorder is prescribed lithium. The nurse should monitor the client for which of the following early signs of toxicity?
- A. Tremors.
- B. Weight loss.
- C. Increased appetite.
- D. Dry skin.
Correct Answer: A
Rationale: Tremors are an early sign of lithium toxicity, requiring prompt monitoring and potential dose adjustment.
A client has a history of syphilis infection. The nurse interprets that the client has been re-infected when which characteristic is noted in a penile lesion?
- A. Papular areas and erythema
- B. Cauliflower-like appearance
- C. Induration and absence of pain
- D. Multiple vesicles, with some that have ruptured
Correct Answer: C
Rationale: The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Scabies is characterized by erythematous, papular eruptions. Genital warts are characterized by cauliflower-like growths, or growths that are soft and fleshy. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal.
A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation?
- A. Use a cool air vaporizer with plain water.
- B. Use saline nose drops and then a bulb syringe.
- C. Blow into the child's mouth to clear the infant's nose.
- D. Administer a nonprescription vasoconstrictive nose spray.
Correct Answer: B
Rationale: Saline nose drops followed by bulb syringe suction is safe and effective for clearing nasal congestion in infants. Vaporizers help with humidity, but saline and suction directly clear the nose.
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says:
- A. If I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: D
Rationale: Clients with preterm labor should get out of the car every 1-2 hours to promote circulation and prevent complications, not every 4 hours, indicating a need for further instruction.