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Which nursing action would be most appropriate if the client develops anorexia and nausea while taking interferon beta-1a (Avonex)?
- A. Withhold the medication.
- B. Offer frequent mouth care.
- C. Administer the drug after meals.
- D. Provide small, easy to digest meals.
Correct Answer: D
Rationale: Providing small, easy-to-digest meals helps manage nausea and encourages nutritional intake without altering the medication schedule.
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Which nursing intervention is most appropriate after the lumbar puncture has been performed?
- A. Keep the client in a side-lying position.
- B. Assist the client into a sitting position.
- C. Withhold food and fluids for 1 hour.
- D. Keep the client flat for several hours.
Correct Answer: D
Rationale: Keeping the client flat for several hours post-lumbar puncture reduces the risk of cerebrospinal fluid leakage and subsequent headache.
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?
- A. I will brush my teeth after every meal.'
- B. I will check my Dilantin level daily.'
- C. My urine will turn orange while on Dilantin.'
- D. I won’t have any seizures while on this medication.'
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene (A) is essential and indicates understanding. Dilantin levels (B) are checked periodically by providers, not daily. Urine color change (C) is not typical, and seizures may still occur (D) if not fully controlled.
The public health nurse is discussing St. Louis encephalitis with a group in the community. Which instruction should the nurse provide to help prevent an outbreak?
- A. Yearly vaccinations for the disease.
- B. Advise that the city should spray for mosquitoes.
- C. The use of gloves when gardening.
- D. Not going out at night.
Correct Answer: B
Rationale: St. Louis encephalitis is mosquito-borne. Mosquito spraying (B) reduces vector populations. No vaccine exists (A), gloves (C) are irrelevant, and night avoidance (D) is less effective.
The 28-year-old client is on the rehabilitation unit post spinal cord injury at level T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply.
- A. Occupational Therapist (OT).
- B. Physical therapist (PT).
- C. Registered dietitian (RD).
- D. Rehabilitation physician.
- E. Social Worker (SW).
- F. Patient care tech (PCT).
Correct Answer: A,B,D,E
Rationale: OT (A) and PT (B) address functional and mobility needs, the physician (D) oversees medical care, and the social worker (E) coordinates resources. Dietitian (C) and PCT (F) are less critical for case conferences.
The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report?
- A. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours.
- B. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan.
- C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6.
- D. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.
Correct Answer: C
Rationale: A GCS score of 6 (C) indicates severe neurological impairment, requiring immediate assessment for potential life-threatening conditions. Waking every 2 hours (A) is standard for concussion, left-sided weakness (B) is concerning but less acute, and expressive aphasia (D) is stable.