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What is your evaluation of Mr. Smith’s skin rash and slight fever after taking INH for 3 months?
- A. Is developing hepatitis
- B. Has not been taking INH
- C. Is having a normal response to the medication
- D. Is demonstrating early signs of drug hypersensitivity
Correct Answer: D
Rationale: The correct answer is D because Mr. Smith's skin rash and slight fever after taking INH for 3 months indicate early signs of drug hypersensitivity. This is supported by the timing of symptoms appearing after prolonged use, which is typical for drug hypersensitivity reactions. Other choices are incorrect: A, developing hepatitis would show different symptoms; B, not taking INH would not explain the symptoms; C, a normal response would not involve rash and fever.
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A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?
- A. Use incentive spirometer every 4 hours while awake.
- B. Initiate ambulation after discontinuing the NG tube.
- C. Maintain a supine position with an abdominal binder.
- D. Splint the incision to support coughing every 2 hours.
Correct Answer: D
Rationale: The correct answer is D because splinting the incision supports coughing, which helps clear secretions and prevents respiratory complications. It is essential postoperatively to prevent atelectasis and pneumonia. Using an incentive spirometer (A) aids in lung expansion but does not directly support coughing. Ambulation (B) promotes circulation but does not address respiratory concerns. Maintaining a supine position with an abdominal binder (C) may restrict diaphragmatic movement and increase the risk of respiratory complications.
Which actions are done primarily by an informatics nurse (select all that apply)?
- A. Designs and builds computer systems
- B. Studies the validity of nursing information
- C. Trains health care providers to provide nursing care
- D. Communicates and accesses information for nursing staff
Correct Answer: A
Rationale: Informatics nurses focus on designing systems, validating information, and building tools to support nursing processes.
Which type of therapy helps clients alter irrational thinking and replace negative self-statements with positive ones?
- A. Desensitization therapy
- B. Behavioral therapy
- C. Cognitive therapy
- D. Psychobiologic therapy
Correct Answer: C
Rationale: Cognitive therapy focuses on identifying and challenging irrational beliefs, helping clients develop healthier thought patterns.
What are the recommendations that can help develop culturally sensitive nursing care?
- A. Learn about different cultures,avoid stereotypes and involve clients in decision-making.
- B. Focus solely on universal care standards.
- C. Ignore cultural differences.
- D. All of the above.
Correct Answer: A
Rationale: Understanding cultural nuances and involving clients in care decisions enhances cultural competence and improves outcomes.
When a client is having a general tonic clonic seizure, the nurse should:
- A. Hold the client's arms at their side.
- B. Place the client on their side.
- C. Insert a padded tongue blade in client's mouth.
- D. Elevate the head of the bed.
Correct Answer: B
Rationale: Placing the client on their side prevents aspiration.