Which instruction should be given regarding the medication used to treat enterobiasis (pinworms)?
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Solution
Answer B is correct. Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answer A is incorrect because children less than 10 can be treated with Vermox. Answer C is incorrect because a single treatment is usually sufficient. Answer D is incorrect because there is no need for IV antibiotics for the client with pinworms.
The 5-year-old is being tested for pinworms. To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
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Solution
Answer A is correct. Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrape the skin, as stated in answer B. Collecting a stool specimen in the afternoon will probably not reveal the eggs because the worms often are not detected during the day; therefore, answer C is incorrect. Answer D is incorrect because eggs are not located in the hair.
The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?
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Solution
Answer D is correct. During ECT, the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Answer A is incorrect because clients are frequently given medication that will cause drowsiness or sleep. Answer B is incorrect because vomiting is not a sign that the ECT has been effective. Answer C is incorrect because tachycardia might be present, but it is not a sign that the ECT has been effective.
Which action by the healthcare worker indicates a need for further teaching?
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Solution
Answer D is correct. It is not necessary to wear gloves to take the vital signs of the client under normal circumstances. If the client has active infection with methicillinresistant staphylococcus aureus, gloves should be worn. The other answer choices indicate knowledge of infection control by the actions, so answers A, B, and C are incorrect.
Which would be an expected finding during injection of dye with a cardiac catheterization?
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Solution
Answer B is correct. It is normal for the client to have a warm sensation when dye is injected. Answer A is incorrect because the client should not have a cold extremity. This indicates peripheral vascular disease. Answer C is incorrect because extreme chest pain can be related to a myocardial infarction. The pain is not normal. Answer D is incorrect because itching is a sign of an allergic reaction. Also, the itching will most likely be on the chest and skin folds
The client is admitted following repair of a fractured femur with cast application. Which nursing assessment should be reported to the doctor?
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Solution
Answer D is correct. Paresthesia, in answer D, is not normal and might indicate compartment syndrome. At this time, pain beneath the cast is normal, so answer A is incorrect. The client’s toes should be warm to the touch and pulses should be present. Because answers B and C are normal findings, these answers are incorrect.
The nurse is evaluating nutritional outcomes for an elderly client with anorexia. Which data best indicates that the plan of care is effective?
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Solution
Answer D is correct. The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet, as in answer A, is of little use if the client does not eat the diet. The hematocrit in answer B is incorrect because although it might improve by several means, such as blood transfusion, it does not indicate improvement in the anorexic condition. The tissue turgor indicates fluid stasis, not improvement of anorexia; therefore, answer C is incorrect.
A client is admitted to the unit 3 hours after an injury with seconddegree burns to the face, neck, and head. The nurse would be most concerned with the client developing which of the following?
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Solution
Answer B is correct. The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A, hypovolemia. Hypernatremia and hyperkalemia, as stated in answers C and D, are incorrect because the client will most likely experience hyponatremia and hypokalemia.
The nurse is caring for a 10-year-old client scheduled for surgery. The client’s mother tells the nurse that her religion forbids blood transfusions. What nursing action is most appropriate?
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Solution
Answer D is correct. If the client’s mother refuses to sign for the child’s treatment, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer A is incorrect because simply documenting the statement is not enough. Answer B is incorrect because it is not the nurse’s responsibility to try to persuade the mother to allow the blood transfusion. Answer C is incorrect because the consequences of the denial of a blood transfusion are not known.
The elderly client with hypomagnesemia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of magnesium sulfate?
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Solution
Answer C is correct. The client receiving magnesium sulfate should have a Foley catheter in place, and the hourly intake and output should be checked because a sign of toxicity to magnesium sulfate is oliguria. There is no need to refrain from checking the blood pressure in the left arm, as stated in answer A. A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion, so this makes answer B incorrect. Answer D is incorrect because just darkening the room will not prevent toxicity, although it might help with the headache associated with preeclampsia.