Nokea
Which of the following signs and symptoms experienced by a child with suspected appendicitis should the nurse correctly judge to be unrelated to the transient sympathetic effects caused by the acute abdominal pain?
- A. Tachycardia.
- B. Chills.
- C. Rapid breathing.
- D. Dilated pupils.
Correct Answer: B
Rationale: Chills are not typically a sympathetic response to pain (unlike tachycardia, rapid breathing, or dilated pupils) and may indicate an infection or other complication.
You may also like to solve these questions
Which of the following suggestions should the nurse give to an adolescent football player with Osgood-Schlatter disease of the left knee?
- A. Apply ice on the knee after playing.
- B. Use crutches until healing has occurred.
- C. Stop playing until healing has occurred.
- D. Make an appointment with a physical therapist.
Correct Answer: A
Rationale: Applying ice after activity reduces inflammation and pain in Osgood-Schlatter disease.
A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Take two puffs twice daily.
Correct Answer: B
Rationale: Rinsing the mouth after using tiotropium prevents oral candidiasis, a common side effect of inhaled anticholinergics.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed apixaban (Eliquis). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild bruising.
- B. Bleeding gums.
- C. Headache.
- D. Nausea.
Correct Answer: B
Rationale: Bleeding gums indicate a potential bleeding complication with apixaban, requiring immediate reporting.
A client is very dependent on the staff but is able to make simple decisions. The client asks, 'Would you do my laundry? I don't know how the machine works.' Which of the following responses would be best?
- A. Sure, I have time; I can do it for you.'
- B. You'll have to wait; I don't have time now.'
- C. Can your family do it for you?'
- D. Get your laundry; I'll show you how the machine works.'
Correct Answer: D
Rationale: Teaching the client to use the machine promotes independence while addressing their request.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with respiratory distress. The nurse should place the client in which of the following positions?
- A. Fowler's position.
- B. Supine position.
- C. Trendelenburg position.
- D. Left lateral position.
Correct Answer: A
Rationale: Fowler's position optimizes lung expansion and eases breathing in COPD.