Nokea
The physician prescribes cimetidine (Tagamet) 300 mg PO qid for a 75-year-old man. The nurse instructs the client about the medication. Which of the following statements, if made by the client, would indicate that further teaching is needed?
- A. I'll take this pill with meals and before bed.
- B. I may experience mild diarrhea for a while.
- C. My stools may change color while I'm on this medication.
- D. I should call my doctor if I get an acne-like rash.
Correct Answer: C
Rationale: no change in stool color
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A client comes to the clinic complaining of severe facial pain. In order to collect subjective data from the client, it is MOST important for the nurse to
- A. obtain the client's vital signs.
- B. interview the client.
- C. inspect the face for grimacing.
- D. administer pain medication.
Correct Answer: B
Rationale: subjective data is collected in the health history or interview
The nursing care plan for a five-year-old with a closed head injury should contain which of the following?
- A. Encourage child to sleep and decrease stimuli in the room.
- B. Assess orientation to person, place, and time every hour.
- C. Notify the physician regarding a negative Babinski reflex.
- D. Increase fluid intake to maintain adequate urinary output.
Correct Answer: B
Rationale: early signs of increased intracranial pressure are alterations in orientation
The nurse is caring for a 34-year-old man admitted with low back pain. The history indicates that the patient has hemophilia A. The nurse should question which of the following orders?
- A. Ketorolac tromethamine (Toradol).
- B. Codeine phosphate (Paveral).
- C. Oxycodone terephthalate (Percodan).
- D. Hydromorphone hydrochloride (Dilaudid).
Correct Answer: C
Rationale: contraindicated for persons with bleeding disorders, contains aspirin
The homecare nurse is visiting an infant who had a myelomeningocele repair.
The homecare nurse determines that the parents are accepting of their infant if which of the following is observed?
- A. The parents state that the infant will outgrow this problem in time.
- B. The parents ask a neighbor to perform bladder expression.
- C. The parents measure the head circumference daily.
- D. The parents relate that they believe the child will walk in one year.
Correct Answer: C
Rationale: Strategy: Think about each statement and how it relates to myelomeningocele. (1) child has a chronic problem (2) indicates the parents' lack of interest and inability to care for the child (3) correct-parents' participation in care may be first sign of acceptance; head circumference measurement is important due to risk of hydrocephalus following surgery; even simple care like bathing child could bring acceptance (4) shows a lack of understanding about myelomeningocele
A 12-year-old boy injured his right knee yesterday during a soccer game.
- A. Which medication is best for a 12-year-old boy with a painful, swollen knee and hemophilia A?
- B. Oxycodone terephthalate (Percodan).
- C. Ibuprofen (Motrin).
- D. Enteric-coated aspirin.
- E. Codeine phosphate (Paveral).
Correct Answer: D
Rationale: Codeine is an appropriate analgesic for moderate to severe pain in hemophilia A, as it does not increase bleeding risk. Oxycodone (contains aspirin), ibuprofen, and aspirin prolong bleeding time and are contraindicated in bleeding disorders.