Nokea
Which basic activity of daily living assistive device can be useful for the client who is affected with poor fine motor coordination?
- A. An aphasia aid
- B. A button hook
- C. Honey thickened liquids
- D. A word board
Correct Answer: B
Rationale: A button hook assists clients with poor fine motor coordination in fastening buttons, supporting independence in dressing.
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A client has been prescribed cyclobenzaprine for the management of muscle spasms. The nurse should observe the client for which most frequent side effect?
- A. Fatigue
- B. Irritability
- C. Excitability
- D. Drowsiness
Correct Answer: D
Rationale: The most frequent side effects of cyclobenzaprine are drowsiness, dizziness, and dry mouth. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasms that accompany a variety of conditions. Fatigue, nervousness, and confusion are rare side effects of the medication.
The nurse is teaching a client with a new diagnosis of asthma about self-management. Which of the following instructions should be included?
- A. Use a peak flow meter daily.
- B. Avoid exercise to prevent attacks.
- C. Take bronchodilators daily.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Daily peak flow meter use monitors lung function and guides asthma management.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart A. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart B. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate’s extremities.
Correct Answer: B
Rationale: The neonate’s Apgar score has been improving since birth. (The birth score is 6; the current score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is
needed since the color is improving, and stimulating the baby is not necessary as the he is now fl exing his extremities.
The mother of a newborn is voicing concerns about her baby's ability to hear. The nurse should tell the mother:
- A. Newborns cannot hear well until they are at least 6 weeks old.
- B. Her concern is unfounded because hearing problems are rare in newborns.
- C. The majority of states now mandate that newborns undergo a screening test for hearing.
- D. The mother can test the baby's hearing by clapping her hands 24 inches from the infant's head.
Correct Answer: C
Rationale: Most states mandate newborn hearing screening to detect issues early, addressing the mother's concern appropriately without dismissing it or suggesting unreliable home testing.
A client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hyperkalemia.
- B. Hypocalcemia.
- C. Hyponatremia.
- D. Hypermagnesemia.
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring.