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A nurse is planning care for a client who has acute appendicitis.
Which of the following actions should the nurse plan to take?
- A. Place the clients head of bed flat
- B. apply heat to the client's abdomen
- C. keep the client on NPO status
- D. administer A laxative to the client
Correct Answer: C
Rationale: The correct answer is C: keep the client on NPO status. This is the correct action as it means "nothing by mouth," which is often necessary before certain medical procedures or surgeries to prevent aspiration. Choice A is incorrect as elevating the head of the bed reduces the risk of aspiration. Choice B is incorrect as heat application may not be indicated and could potentially worsen the client's condition. Choice D is incorrect as administering a laxative may not be appropriate without a proper assessment.
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A school nurse is teaching a parent about absence seizures.
Which information should the nurse include?
- A. This type of seizure can be mistaken for daydreaming
- B. Absence seizures typically last only a few seconds.
- C. The child may not remember the seizure episode afterward.
- D. There are usually no warning signs before an absence seizure occurs.
- E. Lip smacking or eye fluttering may accompany the seizure.
Correct Answer: E
Rationale: The correct answer is E because lip smacking or eye fluttering are common manifestations of absence seizures, providing crucial information for recognition and diagnosis. Choice A is incorrect as it does not specifically relate to absence seizures. Choice B is incorrect because absence seizures typically last 10-20 seconds, not just a few seconds. Choice C is incorrect as individuals experiencing absence seizures usually do not have memory issues afterward. Choice D is incorrect because some individuals may have warning signs before an absence seizure.
A nurse is caring for a client
Nurses: Notes
0800:
A client who has bipolar disorder is admitted to the inpatient psychiatric unit. During the
morning assessment, the client reports blurred vision and an increase in urine output. it's noted
that the client is having clonic jerking of upper extremities: Provider notified and laboratory tests
ordered. Skin is warm and dry without rash.
Complete the following sentence by using the list of options.
The nurse understands that the patient has likely developed lithium toxicity and will be monitored for-------
- A. blood glucose levels
- B. seizure activity
- C. symptoms of infection
- D. temperature over 39.4° C(103\ F)"
Correct Answer: B
Rationale: The correct answer is B: seizure activity. Lithium toxicity can lead to neurological symptoms including seizures. Monitoring for seizure activity is crucial to prevent serious complications. Blood glucose levels (A) are not typically affected by lithium toxicity. Symptoms of infection (C) are unrelated to lithium toxicity. Monitoring temperature (D) is important but not specific to lithium toxicity.
A nurse is caring for an infant who has coarctation of the aorta.
Which finding should the nurse identify as expected?
- A. Weak femoral pulses
- B. Bounding pulses in the lower extremities
- C. Cyanosis of the hands and feet
- D. Frequent episodes of bradycardia
Correct Answer: A
Rationale: The correct answer is A: Weak femoral pulses. In pediatric patients, weak femoral pulses are expected due to the normal physiological differences in vascular resistance between upper and lower extremities. This is known as the "femoral pulse lag." Bounding pulses in the lower extremities (choice B) would be abnormal and could indicate a vascular disorder. Cyanosis of the hands and feet (choice C) suggests poor perfusion and oxygenation, which is concerning. Frequent episodes of bradycardia (choice D) could indicate cardiac issues and are not expected in a healthy pediatric patient.
A nurse is Inserting an indwelling urinary catheter to a male client. Which of the following actions should the nurse take?
- A. Cleanse the tip of the penis in a side to side motion
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Perform the cleansing procedure with a fresh swab two times
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps straighten the urethra, allowing for easier insertion of the catheter. Lifting the penis also reduces the risk of trauma or injury during the procedure. Cleaning the tip of the penis in a side-to-side motion (choice A) can introduce bacteria into the urethra. Picking up the catheter 13 cm (5 in) from its tip (choice B) may contaminate the sterile end. Performing the cleansing procedure with a fresh swab two times (choice C) is not necessary and may increase the risk of irritation to the client's skin.
A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms.
Which of the following statements should the nurse make?
- A. When using implanted contraceptive methods, condoms should also be used to protect against STDs.
- B. Use of petroleum-based lubricant with a condom increases the condom's effectiveness
- C. Ensure that the condom fits snugly over the tip of the penis
- D. Condoms are equally effective for birth control with or without the use of vaginal spermicides
Correct Answer: A
Rationale: The correct answer is A. This statement is correct because implanted contraceptive methods, like hormonal implants, do not protect against sexually transmitted diseases (STDs), so using condoms is necessary for dual protection. Choice B is incorrect as petroleum-based lubricants can weaken condoms. Choice C is incorrect because a condom should fit comfortably, not snugly, to prevent breakage. Choice D is incorrect because condoms are more effective for birth control when used with spermicide.