Nokea
To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?
- A. Stinging, burning when placed under the tongue
- B. Temporary blurring of vision
- C. Generalized urticaria with prolonged use
- D. Urinary frequency
Correct Answer: A
Rationale: Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not even side effects.
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Which person is at greatest risk for developing Lyme disease?
- A. Computer programmer
- B. Elementary teacher
- C. Veterinarian
- D. Landscaper
Correct Answer: D
Rationale: Landscapers are at higher risk for Lyme disease due to frequent outdoor exposure in areas where ticks, which transmit the disease, are prevalent.
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
- A. Insist that she remain at the table and eat a balanced diet.
- B. Order a high-calorie diet with supplements.
- C. Provide nutritious finger foods several times a day.
- D. Offer to go to the dining room with her and allow her to open the food and inspect what she eats.
Correct Answer: C
Rationale: Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating 'on the run,' accommodating their high energy state.
The home health nurse is visiting a client with Paget's disease. An important part of preventive care for the client with Paget's disease is:
- A. Keeping the environment free of clutter
- B. Advising the client to see the dentist regularly
- C. Encouraging the client to take the influenza vaccine
- D. Telling the client to take a daily multivitamin
Correct Answer: A
Rationale: Paget's disease weakens bones, increasing fracture risk. A clutter-free environment prevents falls, a key preventive measure. Dental care, vaccines, and vitamins are less specific.
The nurse is teaching a client with a history of lactose intolerance about dietary modifications. The nurse should tell the client to avoid:
- A. Dairy products
- B. High-fiber foods
- C. Lean meats
- D. Fresh fruits
Correct Answer: A
Rationale: Dairy products contain lactose, which causes gastrointestinal symptoms in lactose intolerance, so they should be avoided.
The client is admitted with a diagnosis of acute diverticulitis. Which dietary order should the nurse anticipate?
- A. High-fiber diet
- B. Low-residue diet
- C. Clear liquid diet
- D. Regular diet
Correct Answer: C
Rationale: A clear liquid diet is ordered during acute diverticulitis to rest the bowel and reduce irritation. High-fiber is for prevention, low-residue is for chronic management, and regular diets are inappropriate.