Nokea
An 8-year-old boy falls off the swings at school and hits his head. He is examined by a physician at an urgent care center, diagnosed with a minor head injury, and sent home.
Which of the following statements, if made by the mother to the nurse, would require further teaching by the nurse?
- A. He should avoid blowing his nose or cleaning his ears for two days.'
- B. I should wake him every 3 hours tonight and tomorrow night to check him.'
- C. I can give him Tylenol every 4 hours if he complains of a headache.'
- D. He will be well enough to play in his soccer game tomorrow.'
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents increased pressure on area (2) should check level of consciousness and orientation every 3-4 hours (3) avoid use of sedatives, sleeping pills, alcohol with head injuries (4) correct-no strenuous activity for 48 hours
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Which diagnosis for the client with tuberculosis would have the greatest impact on public health?
- A. Ineffective breathing pattern
- B. Deficient knowledge
- C. Fatigue
- D. Ineffective family therapeutic regimen management
Correct Answer: B
Rationale: Deficient knowledge about TB transmission risks public health by increasing spread, requiring education to ensure compliance with treatment and precautions.
A client is admitted with acute abdominal pain. Which of the following findings would require immediate attention?
- A. BP 100/50, P 96, abdominal distention
- B. Temperature 99°, flatulence, nausea
- C. Urinary frequency and dysuria
- D. Temperature 99.2°, amber-colored urine
Correct Answer: A
Rationale: Hypotension (BP 100/50), tachycardia (P 96), and abdominal distention suggest a serious condition like internal bleeding or perforation, requiring immediate attention.
The nurse is teaching a client with a new diagnosis of osteoporosis about alendronate (Fosamax). Which of the following instructions should the nurse include?
- A. Take the medication with milk.
- B. Remain upright for 30 minutes after taking.
- C. Stop the medication if bone density improves.
- D. Avoid regular bone density Test s.
Correct Answer: B
Rationale: Remaining upright for 30 minutes prevents esophageal irritation from alendronate. Options A, C, and D are incorrect.
The nurse is caring for a client with a history of Addison’s disease.
- A. Which laboratory finding is most concerning for a client with Addison’s disease?
- B. Serum sodium of 128 mEq/L.
- C. Serum cortisol of 10 µg/dL.
- D. Blood glucose of 90 mg/dL.
- E. Serum potassium of 4.0 mEq/L.
Correct Answer: A
Rationale: A serum sodium of 128 mEq/L indicates hyponatremia, a life-threatening complication in Addison’s disease due to aldosterone deficiency, risking shock. Low cortisol is expected, and normal glucose and potassium are unremarkable.
A pre-term newborn is to be fed breast milk through nasogastric tube. Breast milk is preferred over formula for premature infants because it
- A. Contains less lactose
- B. Is higher in calories/ounce
- C. Provides antibodies
- D. Has less fatty acid
Correct Answer: C
Rationale: Provides antibodies. Breast milk offers maternal antibodies, enhancing immunity in preterm infants.