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When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?
- A. Bread
- B. Oranges
- C. Carrots
- D. Strawberries
Correct Answer: D
Rationale: Strawberries are a common allergen and can cause allergic reactions in some individuals. Allergies to strawberries are relatively common and can present as mild reactions like itching and hives, or more severe symptoms such as difficulty breathing and anaphylaxis. It is important for healthcare professionals, such as nurses, to be aware of common allergens when taking a dietary history from clients to ensure their safety and well-being.
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After receiving an immunization for pediatric diphtheria, tetanus, and acellular pertussis (DTaP), a patient develops swelling and tenderness at the injection site, a low-grade fever, and malaise. The pediatric nurse informs the patient's parents that:
- A. they should delay future immunizations until the patient sees an allergist.
- B. this is a mild reaction, and teaches them how to manage it.
- C. this is an appropriate reaction, and instructs them to do nothing.
- D. none of the above.
Correct Answer: B
Rationale: Mild reactions like swelling, tenderness, low-grade fever, and malaise are common after DTaP vaccination and can be managed with supportive care.
To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should;
- A. Use aseptic technique for the insertion site.
- B. Use clean technique for cleansing connections and aseptic technique for the insertion site.
- C. Use sterile technique when cleansing the insertion site
- D. Close any leaks in the tubing with tape. SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Correct Answer: A
Rationale: To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should use aseptic technique for the insertion site. Aseptic technique involves maintaining a sterile field to prevent the introduction of microorganisms that could lead to infection. Using aseptic technique specifically for the insertion site helps reduce the risk of introducing pathogens into the patient's intracranial system, reducing the chances of infection. Additionally, maintaining a strict aseptic technique is crucial for preventing complications and ensuring patient safety when managing intracranial pressure monitoring systems.
A nurse approaches a hospitalized poststroke patient from the patient's left side to do an assessment. The patient is staring straight ahead, and does not respond to the nurse's presence or voice. Which action should the nurse take first?
- A. Walk to the other side of the bed and try again
- B. Speak more loudly and clearly
- C. Wave his or her fingers in front of the patient's face
- D. Use a picture to explain to the patient what the nurse is going to do.
Correct Answer: A
Rationale: The nurse should walk to the other side of the bed and approach the patient from the right side. Poststroke patients may have neglect syndrome, which can cause them to ignore stimuli on one side of their body. By approaching from the neglected side (the right side in this case), the nurse may be able to better capture the patient's attention and engage them in the assessment process. It is essential to adapt care to accommodate the patient's condition and ensure effective communication and interaction.
Which is descriptive of central nervous system stimulants?
- A. They produce strong physical dependence.
- B. They can result in strong psychological dependence.
- C. Withdrawal symptoms are life threatening.
- D. Acute intoxication can lead to coma.
Correct Answer: B
Rationale: Central nervous system (CNS) stimulants, such as amphetamines and cocaine, are known to produce strong psychological dependence in individuals who use them. These substances can create a powerful craving for their effects due to their ability to increase alertness, attention, and euphoria. Psychological dependence can lead to compulsive drug-seeking behavior, even in the absence of physical withdrawal symptoms. It is important to note that while CNS stimulants can lead to physical dependence, it is typically not as pronounced as the psychological dependence that can develop.
Minda, a 65-year old female has been admitted with a left hemisphere stroke. Which behavioral change would the nurse expect to find upon assessment?
- A. impulsive, unsafe activity
- B. motor deficits on the right eye
- C. motor deficits on the left side of the body
- D. error in word choices
Correct Answer: D
Rationale: A left hemisphere stroke typically affects the right side of the body due to the way the brain controls motor functions. Since the left hemisphere is also responsible for language and speech processing, patients with a left hemisphere stroke commonly exhibit errors in word choices, difficulty speaking or understanding language, aphasia, and other language-related impairments. This is known as Broca's aphasia or expressive aphasia. Therefore, the nurse would expect to find errors in word choices as a behavioral change in a patient like Minda with a left hemisphere stroke.