Nokea
Your neighbor tells you about her preteen son. It seems that he has an ongoing head cold. His sinus is congested; he is not eating regularly and is losing weight. Your neighbor reports that his head cold is so bad that he has to wear sunglasses even in the house. She asks him to remove the glasses but he becomes agitated. You noticed her son is around the neighborhood during school hours when the rest of the family is working. What is your best response?
- A. You better take your son to your doctor immediately. He might have more than a head cold.
- B. Do you notice any money missing from your house?
- C. Is your son going to school?
- D. Your son's condition and behavior does not seem normal. Why don't you ask your practitioner to assess your son.
Correct Answer: D
Rationale: Encouraging professional assessment addresses potential substance abuse or other health issues.
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While recovering from the anesthetic, what is the best position for Mrs. West?
- A. Supine with legs fully extended
- B. Prone with head turned to the side
- C. Lateral Sims with legs flexed
- D. Trendelenburg with head to the side
Correct Answer: D
Rationale: The correct answer is D: Trendelenburg with head to the side. This position helps prevent aspiration by promoting drainage of secretions from the mouth and reducing the risk of airway obstruction. Placing the patient in Trendelenburg position with the head to the side also helps facilitate proper blood flow and ventilation. Supine with legs fully extended (A) may increase the risk of airway obstruction and aspiration. Prone with head turned to the side (B) may obstruct the airway and hinder breathing. Lateral Sims with legs flexed (C) is not suitable for a patient recovering from anesthesia as it may not provide optimal airway clearance and respiratory support.
A client is vomiting. Which of the following actions should the nurse take first?
- A. Provide the client with an emesis basin
- B. Notify housekeeping
- C. Prevent the client from aspirating
- D. Administer an antiemetic to the client
Correct Answer: C
Rationale: The correct action for the nurse to take first is to prevent the client from aspirating. Aspiration is a serious risk when a client is vomiting as it can lead to respiratory complications. The nurse should position the client on their side to prevent aspiration of vomitus into the airway. This immediate action takes priority over providing an emesis basin, notifying housekeeping, or administering an antiemetic, which do not address the urgent need to prevent aspiration.
A patient with a breast biopsy positive for cancer tells the nurse that she has been using information from the Internet to try to make a decision about her treatment choices. In counseling the patient, the nurse knows that (select all that apply)
- A. the patient should be taught how to identify reliable and accurate information available online.
- B. all sites used by the patient should be evaluated by the nurse for accuracy and appropriateness of the information.
- C. most information from the Internet is incomplete and inaccurate and should not be used to make important decisions regarding treatment.
- D. the Internet is an excellent source of health information, and online education programs can provide patients with better instruction than is available at clinics.
Correct Answer: A
Rationale: The correct answers are 'the patient should be taught how to identify reliable and accurate information available online' and 'the patient should be encouraged to use sites established by universities, the government, or reputable health organizations, such as the American Cancer Society, to access reliable information.' These options promote the use of credible sources while discouraging reliance on potentially unreliable information.
Derek has recently converted his outdoor garage to a gym. He has been exercising frequently in his new gym due to the convenience, even in the extreme heat. He has started taking salt tablets. The physician thinks his current symptoms may be owing to hypernatremia. His physician recognizes these as:
- A. Cardiac arrhythmias,palpitations and sinus arrest.
- B. Weakness,dizziness,abdominal distention, nausea ,vomiting, and diarrhea.
- C. Weight gain,irritability,muscle twitching and decreased myocardial contractility.
- D. Muscle cramps,malaise,constipation,rhabdomyolysis and pupillary constriction.
Correct Answer: B
Rationale: The correct answer is Weakness, dizziness, abdominal distention, nausea, vomiting, and diarrhea (B). Hypernatremia occurs when there is an excess of sodium in the body, often due to dehydration or excessive salt intake. Symptoms include gastrointestinal disturbances, neurological symptoms like confusion and dizziness, and muscle weakness.
Yesterday, a male client had a transurethral resection of the prostate (TURP). Today, the client is concerned about the small amount of blood found in his urine. The nurse should explain to the client that the blood:
- A. should not be there on the second day.
- B. will stop when the Foley catheter is removed.
- C. is normal and he should not be concerned.
- D. can be removed by irrigating the bladder.
Correct Answer: C
Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. The client will continue to have a small amount of hematuria even after the Foley catheter is removed. Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. Irrigating the bladder will not remove the hematuria. Irrigation is performed to remove blood clots and to facilitate urinary drainage.