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To which of the following unlicensed assistive personnel should the nurse assign an Hispanic male client who needs complete morning care?
- A. Mary, who has two other clients requiring complete morning care.
- B. Joe, who has one client requiring complete morning care.
- C. Jill, who has four clients requiring partial morning care.
- D. Jim, who has five clients requiring partial morning care.
Correct Answer: B
Rationale: Joe, with only one other client needing complete care, has the lightest workload, making him the best choice for assigning an additional client requiring complete morning care.
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The nurse is conducting health assessments for school-age children. A characteristic behavior of a 7-year-old girl is that she:
- A. Likes to play only with other girls.
- B. Prefers to play with her sister.
- C. Prefers to play team games.
- D. Likes to play alone.
Correct Answer: C
Rationale: At 7 years, children typically enjoy social interaction and team games, reflecting their developmental stage of cooperative play.
A client with a history of ulcerative colitis is prescribed sulfasalazine (Azulfidine). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Avoid sun exposure.
- C. Stop the medication if diarrhea resolves.
- D. Take the medication on an empty stomach.
Correct Answer: B
Rationale: Sulfasalazine can cause photosensitivity, so clients should avoid sun exposure.
Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
- A. Polyuria, nausea, and severe headaches
- B. Polydipsia, translucent skin, and obesity
- C. Fever, tachycardia, and systolic hypertension
- D. Profuse diaphoresis, flushing, and constipation
Correct Answer: C
Rationale: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.
A client with a history of gout is prescribed colchicine. The nurse should instruct the client to take the medication:
- A. Daily to prevent gout attacks.
- B. At the onset of a gout attack.
- C. With meals to enhance absorption.
- D. At bedtime to reduce side effects.
Correct Answer: B
Rationale: Colchicine is most effective when taken at the onset of a gout attack to reduce inflammation and pain.
A client with a history of deep vein thrombosis is prescribed enoxaparin (Lovenox). Which laboratory value does not require routine monitoring?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Hemoglobin
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, does not require routine PT monitoring, unlike warfarin, as it primarily affects anti-factor Xa activity.