Nokea
While awaiting the diagnostic test results for a client with possible meningitis, which transmission-based precautions are the supplement?
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: A
Rationale: Meningitis, especially bacterial, is often transmitted via respiratory droplets, necessitating droplet precautions.
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Which environmental modifications should the nurse implement? Select all that apply.
- A. Keep the room dark and quiet.
- B. Lower the bed to the lowest position.
- C. Keep the side rails up and padded.
- D. Provide soft, soothing music.
- E. Ensure a warm, well-lit room.
- F. Make sure suction equipment is available.
Correct Answer: B,C,F
Rationale: Lowering the bed, padding side rails, and ensuring suction equipment availability reduce injury risk and manage complications during a seizure.
The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidal hypophysectomy. Which preoperative instruction is important for the nurse to teach?
- A. There will be a large turban dressing around the skull after surgery.
- B. The client will not be able to eat for four (4) or five (5) days postop.
- C. The client should not blow the nose for two (2) weeks after surgery.
- D. The client will have to lie flat for 24 hours following the surgery.
Correct Answer: C
Rationale: Blowing the nose (C) risks disrupting the surgical site and causing CSF leaks after transsphenoidal surgery. Turban dressings (A) are not used, eating resumes sooner (B), and flat positioning (D) is not required.
Which client statement indicates a need for further teaching about warfarin therapy?
- A. I'll avoid eating large amounts of spinach.'
- B. I'll take my medication at the same time daily.'
- C. I can take ibuprofen for headaches.'
- D. I'll report any unusual bruising.'
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk with warfarin; the client should use acetaminophen instead.
The husband of a client who is an alcoholic tells the nurse, 'I don’t know what to do. I don’t know how to deal with my wife’s problem.' Which response would be most appropriate by the nurse?
- A. It must be difficult. Maybe you should think about leaving.'
- B. I think you should attend Alcoholics Anonymous.'
- C. I think that Alanon might be very helpful for you.'
- D. You should not enable your wife’s alcoholism.'
Correct Answer: C
Rationale: Alanon (C) supports families of alcoholics, offering coping strategies. Suggesting leaving (A) is judgmental, AA (B) is for alcoholics, and accusing enabling (D) may alienate.
The client comes to the clinic and reports a sudden drooping of the left side of the face and complains of pain in that area. The nurse notes that the client cannot wrinkle the forehead or close the left eye. Which condition should the nurse suspect?
- A. Bell's palsy.
- B. Right-sided stroke.
- C. Tetany.
- D. Mononeuropathy.
Correct Answer: A
Rationale: Bell’s palsy (A) causes unilateral facial drooping, inability to wrinkle the forehead, and eye closure issues due to facial nerve paralysis. Right-sided stroke (B) affects the opposite side, tetany (C) involves muscle spasms, and mononeuropathy (D) is less specific.