Nokea
Which of the following techniques is recommended for removing a tick from the skin?
- A. Grasping the tick with a tissue and quickly jerking it away from the skin
- B. Placing a burning match close the tick and watching for it to release
- C. Using tweezers, grasp the tick close to the skin and pull the tick free using a steady, firm motion
- D. Covering the tick with petroleum jelly and gently rubbing the area until the tick releases
Correct Answer: C
Rationale: Using tweezers to pull the tick steadily minimizes the risk of leaving mouthparts in the skin.
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An elderly preoperative client seems very anxious but denies concerns when the nurse asks; however, the client's son confides that the client is very superstitious and believes it is bad luck that he is in room 113. Which of the following actions is the best response?
- A. Reassure the client that the room number will not affect his surgery outcome.
- B. Contact the admissions department and request that the client be reassigned to a different room.
- C. Ask the physician for medication to relax the client.
- D. Ask the son to stay with the client to reassure him.
Correct Answer: B
Rationale: Reassigning the client to a different room (B) addresses the client's anxiety by respecting his superstitious beliefs, promoting comfort. Reassurance (A), medication (C), or family presence (D) may not fully alleviate the specific concern.
Damage to the VII cranial nerve results in:
- A. Facial pain
- B. Absence of ability to smell
- C. Absence of eye movement
- D. Tinnitus
Correct Answer: C
Rationale: The VII cranial nerve (facial nerve) controls facial muscles; damage causes facial paralysis, affecting eye movement (e.g., inability to close the eye).
A client with bipolar disorder is taking lithium to control symptoms. Which of the following statements indicates the need for further education?
- A. I need to have regular tests for thyroid function.
- B. Once I'm stabilized, I won't need further testing.
- C. I should avoid taking ibuprofen.
- D. It's important for me to avoid dehydration.
Correct Answer: B
Rationale: Lithium requires ongoing monitoring (B is incorrect), as levels and side effects need regular checks. Thyroid tests (A), avoiding ibuprofen (C), and hydration (D) are correct.
The nurse is caring for a client with dementia who tends to wander. Which of the following actions can help with this behavior? Select all that apply.
- A. providing frequent toileting or incontinence care as needed
- B. assessing client for pain and treat with appropriate medications
- C. reorienting the client and use validation therapy, as appropriate
- D. allowing the client to sit in a recliner at the nurses' station for close monitoring
- E. using chemical or physical restraints to prevent the client from exiting the bed
Correct Answer: A, B, C, D
Rationale: Frequent toileting, pain management, reorientation, and close monitoring address wandering causes and promote safety. Restraints are a last resort and not ideal for wandering.
The nurse reviews a 21-year-old female's bloodwork from the lab. Which result would be charted as an abnormal finding?
- A. platelets 129
- B. RBC 4.2
- C. WBC 15.6
- D. hematocrit 38%
Correct Answer: C
Rationale: WBC 15.6 (normal 4.5-11.0 x 10³/μL) is elevated, indicating possible infection or inflammation. Platelets (150-450 x 10³/μL) are slightly low, RBC (4.2-5.4 million/μL) and hematocrit (36-46%) are normal for females.