Nokea
Two Mexican immigrant families live closely together and share goods, services, and childcare. To which of the following family structures does this model correspond?
- A. Kinship network
- B. Binuclear
- C. Nuclear
- D. Extended
Correct Answer: A
Rationale: A kinship network (A) involves close family units sharing resources, typical in some Mexican cultures. Extended (D) is broader, nuclear (C) is single-family, and binuclear (B) involves divorce.
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A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
- A. Withholding all morning medications
- B. Ordering a CBC and CPK
- C. Administering prescribed anti-Parkinsonian medication
- D. Transferring the client to a medical unit
Correct Answer: D
Rationale: Severe muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a medical emergency requiring immediate transfer to a medical unit for treatment.
A student nurse is precepting on the unit and caring for a client with a Dobbhoff nasoenteric tube. Which statement by the student nurse indicates the need for further teaching on caring for a client with this tube? Select all that apply.
- A. I should wait for X-ray confirmation before using the tube.
- B. I can confirm placement by auscultating over the epigastric area.
- C. I can mix liquid medications in with the tube feeding for administration.
- D. I will flush the tube with 20 to 30 mL of water every 4 hours during continuous tube feeding.
- E. I will observe the client for diarrhea, abdominal distention, nausea and vomiting, and tube dislodgement.
Correct Answer: B, C
Rationale: Auscultation is not a reliable method for confirming tube placement; X-ray is required. Mixing medications with feedings can cause clogs or interactions. The other statements are correct.
The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client's care the nurse should:
- A. Maintain strict intake and output
- B. Check the pulse before giving the medication
- C. Administer the medication 30 minutes before meals
- D. Provide oral hygiene and gum care every shift
Correct Answer: D
Rationale: Dilantin can cause gingival hyperplasia, so oral hygiene and gum care are essential to prevent complications.
The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
- A. Intravenous access supplies
- B. Emergency intubation equipment
- C. Intravenous fluid-administration pump
- D. Supplemental oxygen
Correct Answer: B
Rationale: Emergency intubation equipment is essential for LTB due to the risk of airway obstruction requiring immediate intervention.
The nurse has an order to administer 100 units of regular insulin in 500 mL of 0.9% NS to infuse at 12 units per hour. The nurse should program the IV pump to deliver how many mLs per hour?
Correct Answer: 60
Rationale: Concentration: 100 units/500 mL = 0.2 units/mL. To deliver 12 units/hour: 12 ÷ 0.2 = 60 mL/hour.