Nokea
To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to
- A. avoid crowds and obtain an annual influenza vaccination.
- B. drink at least 2 L of fluids daily, including 8 to 10 glasses of water.
- C. eat a potassium-rich, low-sodium diet.
- D. practice good dental hygiene and report gum swelling or bleeding.
Correct Answer: D
Rationale: Phenytoin can cause gum hyperplasia, so good dental hygiene is essential.
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What is a mental status assessment of the older adult especially important in determining?
- A. Potential for independent living
- B. Eligibility for federal health programs
- C. Service and placement needs of the individual
- D. Whether the person should be classified as frail
Correct Answer: C
Rationale: Mental status assessments help determine appropriate services and placements based on cognitive and functional abilities.
Treatment of the patient with appendicitis includes
- A. Transfusion to replace blood loss.
- B. Bowel preparation for cleansing.
- C. Surgical removal of appendix.
- D. Medications to lower pH within stomach.
Correct Answer: C
Rationale: Surgical removal of the appendix is the definitive treatment for appendicitis.
Until Mr. Jones’ diagnosis is confirmed, what should be a priority?
- A. Encouraging rest
- B. Monitoring intake and output
- C. Preventing spread of infection to others
- D. Providing attractive meals
Correct Answer: C
Rationale: The correct answer is C: Preventing spread of infection to others. This is the priority because until Mr. Jones' diagnosis is confirmed, it is crucial to prevent potential transmission of any infectious diseases to others. Encouraging rest (choice A) and providing attractive meals (choice D) are important for overall well-being but not as critical as preventing the spread of infection. Monitoring intake and output (choice B) is important for assessing Mr. Jones' health status but does not directly address the potential risk of infecting others. Therefore, choice C is the most immediate priority to ensure the safety of others.
What statement indicates Mr. Singer understands his condition after viewing a filmstrip on rehabilitation?
- A. ‘I will be able to continue my swimming as usual.’
- B. ‘I will regain some degree of my sense of smell and taste.’
- C. ‘I will not be able to bowl any more.’
- D. ‘I will have to give up my tub bath.’
Correct Answer: B
Rationale: Partial recovery of senses is possible after laryngectomy.
A client is vomiting. Which of the following actions should the nurse take first?
- A. Provide the client with an emesis basin
- B. Notify housekeeping
- C. Prevent the client from aspirating
- D. Administer an antiemetic to the client
Correct Answer: C
Rationale: The correct action for the nurse to take first is to prevent the client from aspirating. Aspiration is a serious risk when a client is vomiting as it can lead to respiratory complications. The nurse should position the client on their side to prevent aspiration of vomitus into the airway. This immediate action takes priority over providing an emesis basin, notifying housekeeping, or administering an antiemetic, which do not address the urgent need to prevent aspiration.