Nokea
The nurse teaches a group of boy scouts how to prevent Lyme disease. Which of the following statements, if made by one of the boy scouts to the nurse, would indicate that further teaching is necessary?
- A. When I go on a long hike, I should check any exposed skin for insects every four hours.
- B. When I hike in the woods, I should wear long pants, socks, and a long-sleeved shirt.
- C. I should remove any ticks by crushing them firmly against the skin.
- D. I should reapply insect repellant every couple of hours when hiking.
Correct Answer: C
Rationale: should not be crushed, remove tick with tweezers or fingers and flush down toilet; burning a tick could spread infection
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The homecare nurse is visiting an infant who had a myelomeningocele repair.
The homecare nurse determines that the parents are accepting of their infant if which of the following is observed?
- A. The parents state that the infant will outgrow this problem in time.
- B. The parents ask a neighbor to perform bladder expression.
- C. The parents measure the head circumference daily.
- D. The parents relate that they believe the child will walk in one year.
Correct Answer: C
Rationale: Strategy: Think about each statement and how it relates to myelomeningocele. (1) child has a chronic problem (2) indicates the parents' lack of interest and inability to care for the child (3) correct-parents' participation in care may be first sign of acceptance; head circumference measurement is important due to risk of hydrocephalus following surgery; even simple care like bathing child could bring acceptance (4) shows a lack of understanding about myelomeningocele
The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest premature labor at 33-weeks gestation. Based on this result, the nurse would anticipate
- A. administration of ritodrine hydrochloride (Yutopar).
- B. initiation of an oxytocin (Pitocin) drip.
- C. delivery of the infant by cesarean section.
- D. continuation of bedrest until otherwise indicated.
Correct Answer: C
Rationale: because the lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants
The nurse is obtaining a history on a client with hyperthyroidism. The nurse should report which of the following assessments to the physician?
- A. Anxiety with extreme nervousness.
- B. Slow, sluggish pulse.
- C. Cool, clammy skin.
- D. Husky, slow speech.
Correct Answer: A
Rationale: signs and symptoms of hyperthyroidism are related to an increased metabolic rate
A client reports that he has been vomiting for three days, has a low-grade temperature, and feels lethargic. Which of the following nursing actions is MOST appropriate in evaluating for fluid volume deficit?
- A. Obtain a urinalysis for casts and specific gravity.
- B. Determine client's weight and assess gain or loss.
- C. Ask client to provide a 24-hour intake and output record.
- D. Determine the quality of the client's skin turgor.
Correct Answer: B
Rationale: daily weight is the best way to evaluate for fluid volume deficit
The nurse is teaching a client with a new diagnosis of depression about citalopram (Celexa). Which of the following statements by the client indicates a need for further teaching?
- A. I should report suicidal thoughts to my doctor.
- B. I should take this medication in the morning.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping citalopram when feeling better is incorrect, as depression requires prolonged treatment to prevent relapse. Options A, B, and C are correct: suicidal thoughts require immediate reporting, morning dosing minimizes insomnia, and alcohol increases sedation.