Nokea
The office nurse receives 4 telephone messages from clients. Which client does the nurse anticipate as the priority for treatment?
- A. 20-year-old college student who reports a ringlike, red bull’s-eye-shaped, itchy leg rash after hiking in the woods 2 days ago
- B. 65-year-old female with pneumonia taking antibiotics who reports white, curdlike vaginal discharge and itching
- C. 78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago
- D. 86-year-old with gout who is prescribed colchicine and reports diarrhea and not feeling well
Correct Answer: C
Rationale: Headaches and gait disturbance in a 78-year-old on warfarin post-fall (C) suggest a possible subdural hematoma, a life-threatening condition requiring immediate evaluation. Bull’s-eye rash (A) suggests Lyme disease, vaginal discharge (B) indicates yeast infection, and diarrhea (D) is a colchicine side effect, all less urgent.
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A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse?
- A. After taking this medication, I will rinse my mouth with water.'
- B. At the first sign of an asthma attack, I will take this medication.'
- C. I have been smoking for 12 years, but I just quit a month ago.'
- D. I received the pneumococcal vaccine about a month ago.'
Correct Answer: B
Rationale: Fluticasone/salmeterol is a maintenance medication for asthma, not a rescue inhaler for acute attacks. Statement B indicates a misunderstanding, requiring further teaching to clarify that a short-acting bronchodilator (e.g., albuterol) should be used for acute symptoms. Rinsing the mouth (A) prevents oral thrush from the steroid component. Quitting smoking (C) and receiving a vaccine (D) are positive health behaviors not requiring correction.
The nurse is talking with a client with macular degeneration. Which of the following statements by the client would be consistent with the condition?
- A. I have been seeing small flashes of light in one eye.
- B. I noticed that my peripheral vision is becoming worse.
- C. I see a blurry spot in the middle of the page when I read.
- D. I cannot see the newspaper unless I hold it away from me.
Correct Answer: C
Rationale: Macular degeneration affects central vision, causing a blurry or dark spot in the visual field, as described in (C), due to damage to the macula. Flashes of light (A) suggest retinal issues, peripheral vision loss (B) is typical of glaucoma, and difficulty reading up close (D) relates to presbyopia.
Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply.
- A. 7 cm x 3 cm x 1 cm stage II decubitus noted on left shin.
- B. 40 u SSRI administered to cover capillary glucose of 160 mg/dL.
- C. Dose of 0.5 mg hydromorphone administered and the client feels better.
- D. 4 Maalox 5 mL PO administered pc as requested for c/o heartburn.
- E. Spouse voiced understanding of home urinary catheterization QID.
Correct Answer: A
Rationale: Metric units (A), decimal doses (C), and QID (E) are clear and acceptable. 'u' (B) risks confusion with '0,' and 'pc' with 'c/o' (D) are ambiguous, per safety standards.
A male client is admitted for evaluation of a sudden hearing loss. No physical cause can be found for his sudden deafness; however, a friend reveals that the client's fiancée recently canceled their engagement, saying that she needed more time to think about the marriage. The client's deafness is an example of:
- A. Conversion reaction
- B. Hypochondriasis
- C. Reaction formation
- D. Histrionic personality disorder
Correct Answer: A
Rationale: Sudden deafness after emotional stress, without physical cause, indicates a conversion reaction, where psychological distress manifests physically.
A client is to be discharged on enoxaparin (Lovenox) for the next two days. Which comment by the client indicates a need for further instruction?
- A. I will wash my hands before I prepare the injection.
- B. I will give the injection in my thigh.
- C. I will pinch the skin before I inject the medicine.
- D. I will not massage the area after the shot.
Correct Answer: B
Rationale: Enoxaparin is injected subcutaneously in the abdomen, not the thigh, indicating a need for further teaching.