Nokea
When admitting a client who has acute glomerulonephritis, the nurse expects that the client will report which information?
- A. Recent bladder infection
- B. History of previous kidney infections
- C. Pharyngitis three weeks ago
- D. Multiple sexual partners
Correct Answer: C
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis. Bladder/kidney infections or sexual partners are less directly related.
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A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection.
The patient's preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment is to
- A. minimize the bacterial count in the mouth.
- B. soften the mucous membranes of the tongue before surgery.
- C. stimulate the microcirculation of the mouth.
- D. hydrate the tissues of the gums.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the procedure. (1) correct-destroys bacteria found in mouth, reduces the chance of infection (2) is not the action of hydrogen peroxide (3) circulation is unaffected by a mouth rinse (4) has slight drying effect on mucous membranes
The nurse is teaching a client with a new diagnosis of type 2 diabetes about metformin (Glucophage). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication with meals.
- B. I should report nausea to my doctor.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping metformin when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: taking with meals reduces GI upset, nausea is a side effect, and alcohol increases lactic acidosis risk.
The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Dry mouth.
- B. Mild sedation.
- C. Muscle stiffness and tremors.
- D. Insomnia.
Correct Answer: C
Rationale: Muscle stiffness and tremors suggest extrapyramidal symptoms, a serious haloperidol side effect. Options A, B, and D are less urgent.
The nurse is caring for a client with a history of peripheral artery disease.
- A. Which symptom is expected in a client with peripheral artery disease?
- B. Warm, red skin on the legs.
- C. Intermittent claudication.
- D. Swelling in the ankles.
- E. Numbness in the arms.
Correct Answer: B
Rationale: Intermittent claudication (leg pain with activity, relieved by rest) is a hallmark of peripheral artery disease due to reduced blood flow. Warm skin and swelling suggest venous issues, and arm numbness is unrelated.
The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
- A. The child is able to state his name when asked who he is.
- B. The child reaches for a stuffed animal brought from home.
- C. The child maintains himself in opisthotonos.
- D. The child withdraws from mildly painful stimuli.
Correct Answer: A
Rationale: Stating his name indicates orientation, a positive sign post-head injury. Options B, C, and D are less reassuring: reaching for a toy is nonspecific, opisthotonos suggests meningeal irritation, and withdrawal may occur in unconscious states.