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Which response will the nurse most likely observe during the caloric test if the client has Meniere's disease?
- A. Onset of severe symptoms
- B. No response or change in symptoms
- C. Improvement in balance
- D. Aphasia and loss of consciousness
Correct Answer: A
Rationale: Meniere's disease causes an exaggerated response to caloric stimulation.
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Which finding of the client's biographical data most likely contributed to developing skin cancer?
- A. The client is a chronic cigarette smoker.
- B. The client has male pattern baldness.
- C. The client works for a drug manufacturer.
- D. The client bathes with a deodorant soap.
Correct Answer: B
Rationale: Baldness increases scalp sun exposure, a risk factor for skin cancer.
The nurse is caring for clients with second- and third-degree burns. Which medication should the nurse plan to apply topically to treat bacterial and yeast infections?
- A. Bismuth subsalicylate
- B. Gold sodium thiomalate
- C. Silver sulfadiazine
- D. Arsenic trioxide
Correct Answer: C
Rationale: Silver sulfadiazine (Silvadene) is a topical anti-infective agent for prevention and treatment of wound infection in second- and third-degree burn clients. Bismuth subsalicylate (Kaopectate) is an antidiarrheal medication. Gold sodium thiomalate (Aurolate) is used to treat rheumatoid arthritis resistant to conventional therapy. Arsenic trioxide (Trisenox) is an antineoplastic.
Which information is most appropriate to include in the discharge instructions for the client who has undergone a cataract extraction?Select all that apply.
- A. Avoid bending over from the waist.
- B. Sleep with the head slightly elevated.
- C. Wash hands before applying eye drops
- D. Sleep with the head elevated
Correct Answer: A,B,C,D
Rationale: Avoiding bending and elevating the head reduce intraocular pressure and promote healing.
Before the client leaves the emergency department, which nursing instruction is most appropriate?
- A. Advise the client to limit dietary intake of fluids.
- B. Tell the client to sleep in a recliner or with the head up.
- C. Show the client how to take the carotid pulse at hourly intervals.
- D. Warn the client to avoid blowing the nose for several hours.
Correct Answer: D
Rationale: Avoiding nose blowing prevents dislodging clots and restarting bleeding.
The nurse observes the unlicensed assistive personnel (UAP) squeezing the 'blackheads' on an elderly client. Which action should the nurse implement first?
- A. Notify the unit manager of witnessing this activity.
- B. Instruct the assistant to stop this behavior.
- C. Demonstrate the correct way to care for the skin.
- D. Complete an incident report regarding the action.
Correct Answer: B
Rationale: Stopping the UAP prevents harm from inappropriate skin manipulation. Notification, demonstration, and reporting follow.