Nokea
When a client of Mexican American descent tells the nurse that she treated her infection by drinking milk, the nurse interprets the client's remark as:
- A. Confusion from fever
- B. Use of the first disease concept
- C. Use of milk as a laxative
- D. The need for a dietitian to assist her with meal planning
Correct Answer: B
Rationale: In Mexican American culture, milk may be used as a traditional remedy for certain conditions, reflecting the ‘hot-cold' disease concept. It's not necessarily confusion, a laxative, or a dietary issue.
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When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?
- A. I need to stay out of the sunlight for 3 days.
- B. The injection site may itch, but I can scratch it if I need to.
- C. I need to avoid sexual intercourse for 2 to 3 days after the vaccination.
- D. I need to prevent becoming pregnant for 2 to 3 months after the vaccination.
Correct Answer: D
Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.
A client with acute pancreatitis is put on nothing-by-mouth status, with the intent of not stimulating the pancreas. The client is prescribed an I.V. infusion of dextrose 5% in half-normal saline solution at 120 mL/hour. After 3 days of this regimen, the nurse should observe the client for which of the following metabolic conditions?
- A. Ketosis.
- B. Hyperglycemia.
- C. Metabolic syndrome.
- D. Lactic acidosis.
Correct Answer: B
Rationale: Dextrose 5% infusion can lead to hyperglycemia, especially in a client with acute pancreatitis, requiring monitoring.
On the night before a 58-year-old wife and mother is to have a lobectomy for lung cancer, she remarks to the nurse, 'I am so scared of this cancer. I should have quit smoking years ago. Now I've brought all this fear and sadness on myself and now my family.' The nurse should tell the client:
- A. It's normal to be scared. I would be, too. We'll help you through it.'
- B. Do you feel guilty because you smoked?'
- C. Don't be so hard on yourself. You don't know if your smoking caused the cancer.'
- D. I can imagine how scared you are. What is it about cancer that you're afraid of?'
Correct Answer: D
Rationale: Acknowledging the client's fear and exploring specific concerns fosters therapeutic communication, helping address her emotions effectively.
When developing the plan of care for a 12-year-old child who is to receive 48 hours of chemotherapy that is associated with nausea and vomiting, at which of the following times should the nurse anticipate administering an antiemetic?
- A. Immediately following chemotherapy.
- B. 30 minutes before the chemotherapy starts, then every 4 to 6 hours.
- C. When the 12-year-old requests medication for nausea, then every 4 hours as needed.
- D. On starting the chemotherapy infusion, and then routinely every 8 hours.
Correct Answer: B
Rationale: Administering an antiemetic 30 minutes before chemotherapy and every 4-6 hours prophylactically minimizes nausea and vomiting.
Which of the following techniques is correct when administering a subcutaneous injection?
- A. Use a 1-inch needle for injection.
- B. Insert the needle at a 45-degree angle to the skin.
- C. Spread the skin tightly at the injection site.
- D. Draw 0.2 mL of air into the syringe before administration.
Correct Answer: B
Rationale: A subcutaneous injection is correctly administered at a 45-degree angle (or 90 degrees for obese patients) using a 5/8-inch needle, pinching the skin, without an air bubble.