Nokea
The parents of an infant ask the nurse in the physician's office what diseases the DPT shot protects against. What should the nurse include when replying?
- A. Diarrhea, polio, and typhoid
- B. Diphtheria, whooping cough, and tetanus
- C. Diarrhea, pertussis, and typhus
- D. Diphtheria, paralysis, and tetany
Correct Answer: B
Rationale: The DPT (DTaP) vaccine protects against diphtheria, pertussis (whooping cough), and tetanus. The other options include incorrect diseases.
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A fifty-five year-old man suffered a left frontal lobe CVA. The patient's family is not present in the room. Which of the following should the nurse watch most closely for?
- A. Changes in emotion and behavior
- B. Monitor loss of hearing
- C. Observe appetite and vision deficits
- D. Changes in facial muscle control
Correct Answer: A
Rationale: The frontal lobe is responsible for behavior and emotions.
The nurse is caring for a client with a history of depression who is receiving bupropion (Wellbutrin) 150 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a dry mouth.
- B. I feel restless sometimes.
- C. I think about ending my life.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of ending life indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on bupropion. Options
A client is diagnosed with bipolar disorder and is in a manic phase with combative behavior.
An INITIAL nursing priority is to
- A. provide adequate hygiene and nutrition.
- B. decrease environmental stimuli.
- C. slowly involve the client in unit activities.
- D. administer and monitor sedative and mood-stabilizing medications.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority (2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression (3) this action is inappropriate at this time (4) correct-is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents
The nurse is performing a sterile dressing change. Which action is essential?
- A. Touching the corners of the dressing with clean gloves
- B. Discussing the wound with the client during the dressing change
- C. Irrigating the wound with an antiseptic solution
- D. Wearing sterile gloves during the dressing change
Correct Answer: D
Rationale: Wearing sterile gloves maintains a sterile field, essential for preventing infection during a sterile dressing change.
A client scheduled for a Nissen repair for a hiatal hernia is being instructed preoperatively to use the incentive spirometer. The nurse determines that the client has understood the teaching when the client states:
- A. These exercises will help to decrease my pain.
- B. I should use this device once a day.
- C. If I use this device, it will help in preventing pneumonia.
- D. I should do these breathing techniques while lying down flat in bed.
Correct Answer: C
Rationale: Incentive spirometry's purpose is to prevent or treat atelectasis, which can lead to pneumonia. Answer A is a false statement, so it is incorrect. Answer B is incorrect because the timing is not as often as it should be. Answer D is wrong because it is best done sitting upright.