Nokea
Which of the following interventions will be most effective in improving transcultural communications with the client?
- A. Use touch to show concern and caring for the client.
- B. Focus attention on verbal communication skills only.
- C. Establish a rapport and listen to their concerns.
- D. Maintain eye contact at all times.
Correct Answer: C
Rationale: Establishing rapport and listening to concerns fosters trust and understanding, which are essential for effective transcultural communication.
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The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate?
- A. The head of the bed elevated 30 to 45 degrees.
- B. Trendelenburg's position.
- C. Left Sims position.
- D. The head elevated on two pillows.
Correct Answer: A
Rationale: Elevating the head of the bed 30 to 45 degrees promotes venous drainage from the brain, reducing ICP. Trendelenburg's position increases ICP by impeding venous return, Sims position is unrelated to ICP management, and pillows may not ensure consistent elevation or neutral neck alignment.
The nurse is planning to give preoperative instructions to a client who will be undergoing rhinoplasty. Which of the following instructions should be included:
- A. After surgery, nasal packing will be in place for 7 to 10 days.
- B. Normal saline nose drops will need to be administered preoperatively.
- C. The results of the surgery will be immediately obvious postoperatively.
- D. Aspirin-containing medications should not be taken for 2 weeks before surgery.
Correct Answer: D
Rationale: Aspirin can increase bleeding risk, so it should be avoided for 2 weeks before surgery. Nasal packing is typically removed within 1–3 days. Saline drops are not routinely required preoperatively. Surgical results may take weeks to months to be fully apparent due to swelling.
A client has been prescribed allopurinol (Zyloprim) for renal calculi that are caused by high uric acid levels. Which of the following indicate the client is experiencing adverse effect(s) of this drug? Select all that apply.
- A. Nausea.
- B. Rash.
- C. Constipation.
- D. Flushed skin.
- E. Bone marrow depression.
Correct Answer: A,B,E
Rationale: Nausea, rash, and bone marrow depression are known adverse effects of allopurinol, indicating potential toxicity or allergic reactions.
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
- A. Constipation.
- B. Hyperkalemia.
- C. Irregular pulse.
- D. Dysuria.
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, so hyperkalemia (B) is a key adverse effect. Constipation (A), irregular pulse (C), and dysuria (D) are not typical.
The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The client understands the discharge plan when the client:
- A. Selects a low-cholesterol diet to control coronary artery disease.
- B. States a need for bed rest for 1 week after discharge.
- C. Verbalizes safety precautions needed to prevent pacemaker malfunction.
- D. Explains signs and symptoms of myocardial infarction (MI).
Correct Answer: C
Rationale: Understanding safety precautions (e.g., avoiding strong electromagnetic fields) prevents pacemaker malfunction, indicating discharge plan comprehension.