Nokea
When determining the parents' compliance with treatment for their child's ear infection, the nurse should ask the parents if they are:
- A. Cleaning the child's ear canals with hydrogen peroxide.
- B. Administering continuous, low-dose antibiotic therapy.
- C. Instilling ear drops regularly to prevent cerumen accumulation.
- D. Holding the child upright when feeding with a bottle.
Correct Answer: D
Rationale: Holding the child upright during feeding prevents milk from entering the Eustachian tube, reducing ear infection risk.
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A 24-year-old nulligravid client with a history of irregular menstrual cycles visits the clinic because she suspects that she is 'about 6 weeks pregnant.' An ultrasound is scheduled in 2 weeks. The nurse should instruct the client that this test will be done to:
- A. Assess gestational age.
- B. Determine a multifetal pregnancy.
- C. Identify the gender of the fetus.
- D. Assess of maternal pelvic adequacy.
Correct Answer: A
Rationale: An early ultrasound at around 8 weeks is primarily used to confirm gestational age and viability.
The nurse is performing an assessment on a client with a diagnosis of systemic lupus erythematosus (SLE). Which finding should the nurse expect to note? Select all that apply.
- A. Fever
- B. Bradycardia
- C. Lymphadenopathy
- D. Butterfly rash on the face
- E. Muscular aches and pains
Correct Answer: A,C,D,E
Rationale: Manifestations of SLE may include fever, musculoskeletal aches and pains, butterfly rash on the face, pleural effusion, basilar pneumonia, generalized lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, seizures, psychosis, and coma.
Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation exercise program. The client is a diabetic and has bilateral leg discomfort with walking. The nurse should advise the client to exercise using a stationary bicycle and intermittent training because of the client's:
- A. Diabetic neuropathy
- B. Muscle atrophy
- C. Raynaud's disease
- D. Transient ischemic attacks
Correct Answer: A
Rationale: Diabetic neuropathy likely causes the client's leg discomfort, making low-impact, intermittent stationary cycling suitable to avoid exacerbating symptoms. Other conditions are less likely causes.
A client with a history of peptic ulcer disease is prescribed misoprostol (Cytotec). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Avoid antacids.
- C. Take the medication at bedtime.
- D. Stop the medication if diarrhea occurs.
Correct Answer: A
Rationale: Misoprostol should be taken with meals to reduce gastrointestinal upset and protect the stomach lining.
A client with a history of multiple sclerosis is admitted with muscle weakness. The nurse should include which of the following in the plan of care?
- A. Assist with activities of daily living.
- B. Restrict physical activity.
- C. Provide a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Assisting with activities of daily living supports safety and independence in multiple sclerosis.