Nokea
The nurse should consider which of the following client reports as an indication of an allergic reaction?
- A. I can't eat broccoli or cabbage when I take my warfarin.'
- B. I get a headache when using my nitroglycerine patch.'
- C. My feet swell when I take felodipine.'
- D. My lips swell when I eat bananas or avocados.'
Correct Answer: D
Rationale: Lip swelling (D) indicates an allergic reaction to food. Broccoli/cabbage (A) affects warfarin's efficacy, headaches (B) are a side effect of nitroglycerin, and swelling (C) is a side effect of felodipine.
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The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply.
- A. Depressed anterior fontanelle
- B. High-pitched cry
- C. Poor feeding
- D. Presence of the Babinski sign
- E. Vomiting
Correct Answer: B, C, E
Rationale: High-pitched cry (B), poor feeding (C), and vomiting (E) are signs of bacterial meningitis in infants. A depressed fontanelle (A) suggests dehydration, not meningitis, and Babinski sign (D) is normal in infants.
A client with borderline personality disorder says to the nurse, 'You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you.' What is the priority nursing action?
- A. Assign different staff members to care for the client each day
- B. Assign the client's stated preferred nurse to care for the client
- C. Reassure the client that all staff members are competent in their jobs
- D. Reinforce unit guidelines and appropriate boundaries with the client
Correct Answer: D
Rationale: Reinforcing boundaries (D) addresses splitting behavior and maintains therapeutic relationships. Rotating staff (A), assigning the preferred nurse (B), or reassuring competence (C) may reinforce manipulation.
A client with Addison's disease will most likely exhibit which symptom?
- A. Hypertension
- B. Bronze pigmentation
- C. Hirsutism
- D. Purple striae
Correct Answer: B
Rationale: A bronze pigmentation is a sign of Addison's disease. Answers A, C, and D are symptoms of Cushing's syndrome, making them incorrect.
A nurse is reinforcing teaching to the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching?
- A. My child may experience incontinence.'
- B. My child may seem confused afterwards.'
- C. My child may stare and seem inattentive.'
- D. My child will notice unusual odors prior to the event.'
Correct Answer: C
Rationale: Staring and inattention (C) are hallmark signs of absence seizures. Incontinence (A) and confusion (B) are more typical of other seizures, and odors (D) suggest an aura, not typical in absence seizures.
Diagnosis-related groups (DRGs) provide data to
- A. Identify clients who have specific medical diagnoses
- B. Identify findings related to a medical diagnosis
- C. Determine reimbursement for a medical diagnosis
- D. Implement nursing care based on case management protocol
Correct Answer: C
Rationale: Determine reimbursement for a medical diagnosis. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.