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When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:
- A. Fruit juices
- B. Diluted carbonated drinks
- C. Soy-based, lactose-free formula
- D. Regular formulas mixed with electrolyte solutions
Correct Answer: C
Rationale: Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea. Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhea. Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. Regular formulas contain lactose, which can increase diarrhea.
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The nurse is caring for a client with a diagnosis of postpartum endometritis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for cesarean delivery
- D. Administer tocolytics
Correct Answer: A
Rationale: Postpartumndometritis require es antibiotics to treat the uterine infection. Fetal heart tones are irrelevant postpartum cesarean delivery is not indicated and tocolytics are for preterm labor.
A 24-year-old client presents to the emergency department protesting 'I am God.' The nurse identifies this as a:
- A. Delusion
- B. Illusion
- C. Hallucination
- D. Conversion
Correct Answer: A
Rationale: A delusion is a false belief, such as claiming to be God, common in psychotic disorders.
Upon admission to the hospital, a client reports having "the worst headache I've ever had." The nurse should give the highest priority to which action?
- A. Administering pain medication
- B. Starting oxygen
- C. Performing neuro checks
- D. Inserting a Foley catheter
Correct Answer: C
Rationale: A severe headache may indicate a neurological emergency (e.g., subarachnoid hemorrhage). Neuro checks (C) assess for deterioration. Pain medication (A), oxygen (B), and Foley (D) are secondary.
A client with AIDS tells the nurse that he has been using herbal supplements in addition to the regimen of drugs prescribed by the physician. The nurse should tell the client that:
- A. Most herbals are well suited to use with prescription medications.
- B. He should buy only FDA-approved herbal supplements for use.
- C. The use of herbals may alter the effect of the medication he is taking.
- D. The herbal supplements should be taken at the same time as his medication.
Correct Answer: C
Rationale: Herbal supplements can interact with antiretroviral drugs, altering their efficacy or toxicity (e.g., St. John’s wort reduces protease inhibitor levels). The nurse should advise the client to discuss herbals with the physician, as they are not inherently safe or FDA-regulated for this purpose.
The nurse is caring for a client with a suspected stroke. Which assessment finding is most concerning?
- A. Mild headache
- B. Unilateral facial droop
- C. Slight dizziness
- D. Fatigue
Correct Answer: B
Rationale: Unilateral facial droop is a classic sign of stroke, indicating neurological deficit and requiring urgent evaluation. Headache (A), dizziness (C), and fatigue (D) are less specific.