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The nurse is teaching family members how to correctly transfer a client who has right hemiplegia from the bed to a wheelchair. Which observation indicates that the family understands how to transfer the client?
- A. The wheelchair is placed parallel to the bed on the affected side.
- B. The family members lift the client up by having her place her arms around their necks.
- C. The wheelchair is placed at a 45-degree angle to the bed on the client's unaffected side.
- D. The family members ask for a trapeze bar for the client to use in the transfer.
Correct Answer: C
Rationale: Placing the wheelchair at a 45-degree angle on the unaffected side allows the client to pivot using their stronger left side, ensuring a safe transfer. Affected-side placement or neck lifting is unsafe, and a trapeze is unnecessary.
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The nurse is instructing a client being discharged on tranylcypromine sulfate (Parnate).
The nurse knows further instruction is needed if the client makes which of the following statements?
- A. To celebrate, my wife and I are going out for pepperoni pizza and wine tonight.'
- B. I plan to use sunblock at the beach this summer.'
- C. When I get home, I am going to start a diet so I can lose some weight.'
- D. Now that I feel so much better, I have more energy.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to Parnate. (1) correct-Parnate is a MAO inhibitor; must avoid food with tyramine (aged cheese, yogurt, beer, wine) to prevent hypertensive crisis (2) sunblock required (3) no contraindication to sensible weight reduction diet (4) expected outcome of antidepressant; takes 3-4 weeks to work
The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except:
- A. disclose the information before the child knows or suspects.
- B. be comfortable with your sexual preference first.
- C. have the discussion in a quiet place where interruptions are unlikely.
- D. explain how your relationship with the child changes because of the discussion.
Correct Answer: D
Rationale: Children of gay and lesbian parents should be reassured that their relationship with their parent will not change because of the discussion.
A diagnosis of pernicious anemia is made by:
- A. Bone marrow aspiration
- B. Quantitative assay
- C. Weber test
- D. Schilling test
Correct Answer: D
Rationale: The Schilling test diagnoses pernicious anemia by assessing vitamin B12 absorption. Bone marrow aspiration, quantitative assays, or the Weber test (hearing) are not specific to this condition.
A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings?
- A. Hypotension, backache, low back pain, fever.
- B. Wet breath sounds, severe shortness of breath.
- C. Chills and fever occurring about an hour after the infusion started.
- D. Urticaria, itching, respiratory distress.
Correct Answer: A
Rationale: signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea, cyanosis, chest pains, tachycardia, and hypotension
During seizure activity which observation is the priority to enhance further direction of treatment?
- A. Observe the sequence or types of movement
- B. Note the time from beginning to end
- C. Identify the pattern of breathing
- D. Determine if loss of bowel or bladder control occurs
Correct Answer: A
Rationale: Observe the sequence or types of movement. Noting movement types is critical for diagnosis and guiding treatment.