Nokea
The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse?
- A. Bring the child to the health care provider's (HCP) office immediately.
- B. Give your child something warm to drink.
- C. Massage the child's feet gently until they warm up.
- D. Place the child's feet in warm water immediately.
Correct Answer: D
Rationale: Red and swollen feet suggest frostbite or cold injury. Immersing the feet in warm (not hot) water is the safest and most effective way to rewarm the tissue and prevent further damage.
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A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
- A. A social worker from the local hospital
- B. A physical therapist to improve fine motor coordination
- C. An activity therapist from the community center
- D. Another client with diabetes mellitus and takes insulin
Correct Answer: B
Rationale: A physical therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.
The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.
- A. Assist the client to ambulate in the hallway every shift
- B. Encourage the client to increase sodium intake
- C. Maintain the client in semi-Fowler position
- D. Provide an alternating air pressure mattress for the client
- E. Use music to provide a distraction for the client
Correct Answer: C,D,E
Rationale: Semi-Fowler position helps alleviate shortness of breath by reducing pressure on the diaphragm. An alternating air pressure mattress reduces the risk of pressure injuries due to immobility. Music can help reduce discomfort and anxiety, providing a non-pharmacological distraction.
A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?
- A. Have an ophthalmologic examination every 6 months
- B. Take the medication on an empty stomach
- C. Take vitamin D and calcium supplements
- D. Wear a MedicAlert bracelet
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity. Regular ophthalmologic exams every 6 months are essential to monitor for early signs of retinal damage.
Vital signs
Temperature 98.2 F (36.7 C)
Blood pressure 108/72 mm Hg
Heart rate 62/min
Respirations 16/min
SpO2 96% on room air
A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply.
- A. How to take own pulse
- B. Monitoring daily weight
- C. Need for monthly International Normalized Ratio testing
- D. Need to increase foods high in potassium
- E. Reduction of sodium in diet
- F. Use of home oxygen
Correct Answer: A,B,E
Rationale: Taking pulse (A), monitoring weight (B), and reducing sodium (E) help manage heart failure by tracking symptoms, detecting fluid retention, and preventing exacerbation.
A 6-year-old was just diagnosed with pediculosis capitis. Which comment by the mother of the child indicates to the nurse in the physician's office that she does not understand how this condition is spread?
- A. I need to wash all his bed sheets in hot water.'
- B. I will call the school nurse and tell her.'
- C. I think he got this at our neighbor's house; it's very dirty.'
- D. I will tell my son not to wear other children's hats.'
Correct Answer: C
Rationale: Blaming a dirty house misrepresents lice transmission, which occurs via direct head-to-head contact or sharing items, indicating misunderstanding.