Nokea
The nurse working in an outpatient clinic is preparing to teach insulin injection to an elderly male client who is hard of hearing yet refuses to wear prescribed hearing aids. Which of the following communication strategies would be most appropriate for the nurse to use?
- A. speak in a high-pitched voice
- B. use sign language
- C. ensure the room.Concurrent is well lit
- D. refrain from touching the client
Correct Answer: C
Rationale: A well-lit room enhances visual cues, aiding communication for a client with hearing difficulties who relies on lip-reading or facial expressions.
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The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
- A. Determine lung maturity
- B. Measure the fetal activity
- C. Show the effect of contractions on fetal heart rate
- D. Measure the well-being of the fetus
Correct Answer: D
Rationale: A nonstress test assesses fetal well-being by monitoring fetal heart rate in response to movement, particularly in high-risk pregnancies.
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Sydenham's chorea?
- A. Irregular movements of the extremities and facial grimacing
- B. Painless swellings over the extensor surfaces of the joints
- C. Faint areas of red demarcation over the back and abdomen
- D. Swelling, inflammation, and effusion of the joints
Correct Answer: A
Rationale: Sydenham's chorea, a manifestation of rheumatic fever, is characterized by irregular, involuntary movements and facial grimacing.
The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
- A. Dried beans
- B. Nuts
- C. Cheese
- D. Eggs
Correct Answer: A
Rationale: Dried beans are high in purines, which can increase uric acid levels and exacerbate gout symptoms.
To ensure safety while administering a nitroglycerine patch, the nurse should:
- A. Wear gloves while applying the patch.
- B. Shave the area where the patch will be applied.
- C. Wash the area thoroughly with soap and rinse with hot water.
- D. Apply the patch to the buttocks.
Correct Answer: A
Rationale: Gloves prevent the nurse from absorbing nitroglycerin, avoiding side effects.
The nurse is teaching a client with peritoneal dialysis how to manage exchanges at home. The nurse should tell the client to notify the doctor immediately if:
- A. The dialysate returns become cloudy in appearance.
- B. The return of the dialysate is slower than usual.
- C. A 'tugging' sensation is noted as the dialysate drains.
- D. A feeling of fullness is felt when the dialysate is instilled.
Correct Answer: A
Rationale: Cloudy dialysate indicates possible peritonitis, a serious infection requiring immediate medical intervention to prevent complications.