Nokea
A 26-year-old woman is admitted to the neurosurgery unit for the removal of a cerebellar tumor.
The nurse would expect the patient to make which of the following statements about her symptoms?
- A. I have been having difficulty with my hearing.'
- B. I lose my balance easily.'
- C. I can't tell the difference between a sweet and sour taste.'
- D. It is not easy for me to remember names and faces.'
Correct Answer: B
Rationale: Strategy: Remember physiology. (1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic (2) correct-cerebellum maintains balance (3) CN IX, glossopharyngeal responsible for differentiation of taste (4) not specific symptoms of cerebellum dysfunction
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The nurse is teaching a client with a new diagnosis of heart failure about furosemide (Lasix). Which of the following statements by the client indicates a need for further teaching?
- A. I should report muscle cramps to my doctor.
- B. I should take this medication in the morning.
- C. I should eat foods high in potassium.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping furosemide when feeling better is incorrect, as heart failure requires lifelong treatment to manage fluid overload. Options A, B, and C are correct: muscle cramps may indicate hypokalemia, morning dosing minimizes nocturia, and potassium-rich foods are recommended.
The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition?
- A. Solid foods should be introduced at 3-4 months
- B. Whole milk is difficult for a young infant to digest
- C. Fluoridated tap water should be used to dilute milk
- D. Supplemental apple juice can be used between feedings
Correct Answer: B
Rationale: Cow's milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and creates a high renal solute load.
A client diagnosed with chronic depression is maintained on tranylcypromine (Parnate). An important nursing intervention is to teach the client to avoid which of the following foods?
- A. Wine, beer, cheese, liver and chocolate
- B. Wine, citrus fruits, yogurt and broccoli
- C. Beer, cheese, beef and carrots
- D. Wine, apples, sour cream and beef steak
Correct Answer: A
Rationale: These foods are tyramine-rich and ingestion of these foods while taking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.
The nurse is providing home care to a 78-year-old woman who has early dementia. The client tells the nurse, 'My daughter is mean to me.' What should the nurse do initially?
- A. Report suspected elder abuse to the supervisor
- B. Report elder abuse to the authorities
- C. Ask the daughter about the mother's comment
- D. Ask the client to describe what the daughter does to be mean to her
Correct Answer: D
Rationale: The client's statement is very vague and needs to be clarified. Initially, the nurse should ask the client what the daughter does to her that is mean. Examples of behavior are important in evaluating whether the client is the victim of abuse or whether the client's dementia is affecting her perceptions. The nurse does not have enough data at this point to report the client's claim. Initially the nurse should clarify the accusation with the client. After doing that, it would be appropriate to discuss the issue with the daughter.
A 22 year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?
- A. The patient is excited about being around family again.
- B. The patient's suicide plan has probably progressed.
- C. The patient's plans for the future have been clarified.
- D. The patient's mood is improving.
Correct Answer: B
Rationale: The suicide plan may have been decided.