Nokea
The nurse teaches a client taking desmopressin (DDAVP) nasal spray about how to manage treatment. The nurse determines that the client needs additional instruction when he makes which of the following comments?
- A. I should check for sores in my nose while taking this medication.'
- B. I should use the same nostril each time I take the medicine.'
- C. I should report nasal congestion.'
- D. I should report any signs of respiratory infection.'
Correct Answer: B
Rationale: Using the same nostril each time can cause irritation or reduced efficacy; alternating nostrils is recommended. The other comments reflect correct understanding of desmopressin use.
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The nurse teaches a pregnant client to perform Kegel exercises. Which statement by the client indicates an understanding of the purpose of these types of exercises?
- A. The exercises will help reduce backache.
- B. The exercises will help prevent ankle edema.
- C. The exercises will help strengthen the pelvic floor.
- D. The exercises will help prevent urinary tract infections.
Correct Answer: C
Rationale: Kegel exercises assist in strengthening the pelvic floor (pubococcygeal muscle). Pelvic tilt exercises help reduce backaches. Leg elevation assists in preventing ankle edema. Instructing a client to drink 8 ounces of fluids 6 times a day helps prevent urinary tract infections.
The nurse is teaching a client with a new diagnosis of gout about medication management. Which of the following medications should the client expect to take for long-term management?
- A. Allopurinol.
- B. Colchicine.
- C. Indomethacin.
- D. Prednisone.
Correct Answer: A
Rationale: Allopurinol reduces uric acid production for long-term gout management.
The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful?
- A. Place bedside articles on the left side.
- B. Approach the client from the right side.
- C. Teach the client to scan the environment.
- D. Move the commode and chair to the left side.
Correct Answer: B
Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well.
A nurse is having difficulty establishing a relationship with an aggressive client. What strategy will most likely improve the relationship?
- A. The nurse and the client agree to work to improve their involvement in the therapeutic relationship.
- B. The nurse establishes goals for having only positive interactions with the client.
- C. The nurse agrees to be submissive so the client can dominate the relationship.
- D. The nurse seeks assistance from colleagues to become more aware of the quality of the interactions and more sensitive to the dynamics of communication.
Correct Answer: D
Rationale: Seeking colleague assistance enhances self-awareness and communication skills, improving the therapeutic relationship with an aggressive client.
The client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which of the following? Select all that apply.
- A. Vertigo.
- B. Tinnitus.
- C. Nausea.
- D. Ataxia.
- E. Hearing loss.
Correct Answer: A,C,D
Rationale: Ototoxicity affecting the vestibular branch causes vertigo, nausea, and ataxia due to balance disruption. Tinnitus and hearing loss are associated with cochlear branch damage.