A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?
Answer : A
This statement reveals cultural sensitivity. Ginger is sometimes used to relieve nausea. The other statements are culturally insensitive and do not show an awareness of herbal pharmacology. Physiological Adaptation
Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting?
Answer : B
Zofran is a serotonin antagonist that can be used to relieve nausea and vomiting. The other medications can be used for nausea and vomiting, but they have different mechanisms of action. Physiological Adaptation
Which of the following is likely to increase the risk of sexually transmitted disease?
Answer : D
STDs affect certain groups in groups in greater numbers. Factors associated with risk include being younger than 25 years of age, being a member of a minority group, residing in an urban setting, being impoverished, and using crack cocaine. Physiological Adaptation
Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of:
Answer : B
Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment. Physiological Adaptation
The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines:
Answer : D
Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases.
The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the worlds population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine childhood immunization. They have not, however, been eradicated, so children need to be immunized against these diseases. Physiological Adaptation
Acyclovir is the drug of choice for:
Answer : B
Acyclovir (Zovirax) is specific for treatment of herpes virus infections. There is no cure for herpes. Acyclovir is excreted unchanged in the urine and therefore must be used cautiously in the presence of renal impairment.
Drugs that treat herpes inhibit viral DNA replication by competing with viral substrates to form shorter, ineffective DNA chains. Physiological Adaptation
A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:
Answer : B
Moving the wheelchair close to clients bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb. Basic Care and Comfort
Assessment of a client with a cast should include:
Answer : A
Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill, cool fingers or toes, and pain. Basic Care and Comfort
In teaching clients with Buck’s Traction, the major areas of importance should be:
Answer : C
Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids. Basic Care and Comfort
When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing:
Answer : D
The usual recommendation for treatment of hypoglycemia is 1015 grams of a fast-acting simple carbohydrate, orally, if the client is conscious and able to swallow
(for example, 34 commercially prepared glucose tablets or 46 oz of fruit juice). It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level. Addition of sugar might result in a sharp rise in blood sugar that could last for several hours. Physiological Adaptation
A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The clients weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:
Answer : C
Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This clients
BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a clients BMI, activity status, and energy requirements. Physiological Adaptation
Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
Answer : C
A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions. Physiological Adaptation
Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
Answer : C
Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident. Physiological Adaptation
Which of the following terms refers to soft-tissue injury caused by blunt force?
Answer : A
A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress.
A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact. Physiological Adaptation
A client with dumping syndrome should ___________ while a client with GERD should ___________.
Answer : B
Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus. Basic Care and Comfort
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