Nokea
A six-month-old infant has had all of the required immunizations.
The nurse knows this would include which of the following?
- A. Two doses of diphtheria, tetanus, and pertussis vaccine.
- B. Measles, mumps, and rubella vaccines.
- C. A booster dose of the trivalent oral polio vaccine.
- D. Chickenpox and smallpox vaccines.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-first dose of the DPT may be given at two months, the second is given around four months (2) MMR is given at 15 months (3) polio is given at two and four months and again at 12 to 18 months (4) smallpox vaccine is no longer recommended
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The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about methotrexate (Rheumatrex). Which of the following statements by the client indicates a need for further teaching?
- A. I should avoid drinking alcohol while taking this medication.
- B. I should take this medication with food.
- C. I should report any bruising to my doctor.
- D. I should stop this medication if my joints feel better.
Correct Answer: D
Rationale: Stopping methotrexate when joints feel better is incorrect, as rheumatoid arthritis requires ongoing treatment to prevent flares. Options A, B, and C are correct: alcohol increases hepatotoxicity, food reduces GI upset, and bruising may indicate thrombocytopenia.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which of the following statements by the client indicates a need for further teaching?
- A. I should avoid lying down for 2 hours after eating.
- B. I should eat smaller, more frequent meals.
- C. I should avoid drinking coffee in the evening.
- D. I should sleep on my right side to reduce reflux.
Correct Answer: D
Rationale: Sleeping on the right side can worsen GERD by allowing acid to reflux into the esophagus; the left side or head elevation is preferred. Options A, B, and C are correct: avoiding lying down post-meal, eating smaller meals, and avoiding coffee reduce reflux.
A client who has had a right below-the-knee amputation refers to himself as 'a freak' and 'old peg-leg.' What initial response by the nurse is most therapeutic?
- A. You are not a freak.'
- B. Lots of people have amputations and live a normal life.'
- C. You feel like a freak.'
- D. You shouldn't say that; you are very attractive.'
Correct Answer: C
Rationale: Reflecting the client's feelings ('You feel like a freak') validates their emotions, promoting therapeutic communication. Denying, normalizing, or reassuring dismisses their distress.
A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being 'too sick to return to work.' The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that the client's behavior
- A. Is controlled by their subconscious mind
- B. Is manipulative to avoid work responsibilities
- C. Would respond to psychoeducational strategies
- D. Could be modified through reality therapy
Correct Answer: A
Rationale: Is controlled by their subconscious mind. Somatoform disorder involves involuntary physical complaints driven by psychological factors, not conscious manipulation.
The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are
- A. sedation as needed to prevent exhaustion
- B. antibiotic therapy for 10 to 14 days
- C. humidified air and increased oral fluids
- D. antihistamines to decrease allergic response
Correct Answer: C
Rationale: humidified air and increased oral fluids. The most important aspects of home care for a child with acute spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids in mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.