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Tom has Guillain-Barré syndrome and asks what causes his burning, prickling feeling. You respond by saying
- A. You are lying too long on the affected side.
- B. This is in response to your medication.
- C. The myelin cover of the nerve endings is absent.
- D. This is secondary to dysphagia.
Correct Answer: C
Rationale: Guillain-Barré syndrome damages the myelin sheath, leading to abnormal sensations.
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Identify the specific component of acquiring cultural competence reflected in creating a safe environment in which collection of relevant cultural data can be obtained during the health history and physical examination.
- A. Cultural skill
- B. Cultural encounter
- C. Cultural awareness
- D. Cultural knowledge
Correct Answer: A
Rationale: Creating a safe environment involves using cultural skills to gather accurate and meaningful cultural data during assessments.
How should the nurse respond to Mrs. West’s statement, “Oh well, I have already lived my life anyway.”
- A. “Oh, you have nothing to worry about Mrs. West. We’re going to take good care of you.”
- B. “You feel that your life is ending, Mrs. West? Can you tell me more about your feelings?”
- C. “Your doctor is one of the best and our surgical staff is excellent.”
- D. “The x-rays indicate that your tumor is accessible and the surgery will cure your problem.”
Correct Answer: B
Rationale: Encouraging the patient to express feelings fosters trust and understanding.
The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that:
- A. The client should remain on bed rest in a semi-Fowler's position.
- B. The client should alternate ambulation with bed rest with legs elevated.
- C. The client may ambulate and sit in chair as tolerated.
- D. The client may ambulate as tolerated and remain in semi-Fowlers positioning bed.
Correct Answer: D
Rationale: Semi-Fowler's position aids in breathing and reduces pressure on the abdomen.
For care of a patient who has oral cancer, which task would be appropriate to delegate to the LPN/LVN?
- A. Assist the patient to brush and floss.
- B. Give antacids and sucralfate suspension as ordered.
- C. Recommend saliva substitutes.
- D. Explain when brushing and flossing are contraindicated.
Correct Answer: A
Rationale: Assisting with oral hygiene is within the scope of practice for LPNs/LVNs, while medication administration and patient education require higher-level training.
Which statements are correct for lithium?
- A. Effective for all
- B. Has a delay of 10 to 28 days in achieving therapeutic benefits
- C. Has a narrow range of safety between a therapeutic serum level and toxic levels
- D. May be therapeutic when administered in combination with any other drugs
Correct Answer: C
Rationale: Lithium has a narrow therapeutic window, requiring careful monitoring to prevent toxicity.