An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse’s discharge teaching?
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Solution
Answer A is correct. After hypospadias repair, the child will need to avoid straddle toys, such as a rocking horse, until allowed by the surgeon. Swimming and rough play should also be avoided. Answers B, C, and D do not relate to the post-operative care of the child with hypospadias; therefore, they are incorrect.
The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates that the client understands his new diet?
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Solution
Answer C is correct. Oatmeal is low in sodium and high in fiber. Limiting sodium intake and increasing fiber helps to lower cholesterol levels, which reduce blood pressure. Answer A is incorrect because cornflakes and whole milk are higher in sodium and are poor sources of fiber. Answers B and D are incorrect choices because they contain animal proteins that are high in both cholesterol and sodium.
A client is hospitalized with hepatitis A. Which of the client’s regular medications is contraindicated due to the current illness?
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Solution
Answer D is correct. Lipid-lowering agents are contraindicated in the client with active liver disease. Answers A, B, and C are incorrect because they are not contraindicated in the client with active liver disease.
The mother of a child with cystic fibrosis tells the nurse that her child makes “snoring” sounds when breathing. The nurse is aware that many children with cystic fibrosis have:
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Solution
Answer B is correct. Children with cystic fibrosis are susceptible to chronic sinusitis and nasal polyps, which might require surgical removal. Answer A is incorrect because it is a congenital condition in which there is a bony obstruction between the nares and the pharynx. Answers C and D are not specific to the child with cystic fibrosis; therefore, they are incorrect.
The physician has ordered Stadol (butorphanol) for a postoperative client. The nurse knows that the medication is having its intended effect if the client:
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Solution
Answer A is correct. Stadol reduces the perception of pain, which allows the postoperative client to rest. Answers B and C are not affected by the medication; therefore, they are incorrect. Relief of pain generally results in less nausea, but it is not the intended effect of the medication; therefore, answer D is incorrect.
The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:
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Solution
Answer B is correct. The client’s diabetes is well under control. Answer A is incorrect because it will lead to elevated blood sugar levels and poorer control of the client’s diabetes. Answer C is incorrect because the diet and insulin dose are appropriate for the client. Answer D is incorrect because the desired range for glycosylated hemoglobin in the adult client is 2.5%–5.9%.
Which activity is best suited to the 12-year-old with juvenile rheumatoid arthritis?
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Solution
Answer B is correct. Exercises that provide light passive resistance are best for the child with rheumatoid arthritis. Answers A and C require movement of the hands and fingers that might be too painful for the child with juvenile rheumatoid arthritis; therefore, they are incorrect. Answer D is incorrect because it requires the use of larger joints affected by the disease.
A client with schizoaffective disorder is exhibiting Parkinsonian symptoms. Which medication is responsible for the development of Parkinsonian symptoms?
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Solution
Answer A is correct. A side effect of antipsychotic medication, such as Zyprexa, is the development of Parkinsonian symptoms. Answers B and C are incorrect choices because they are used to reverse Parkinsonian symptoms in the client taking antipsychotic medication. Answer D is incorrect because the medication is an anticonvulsant used to stabilize mood. Parkinsonian symptoms are not associated with anticonvulsant medication.
A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:
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Solution
Answer D is correct. Absence seizures, formerly known as petit mal seizures, are characterized by a brief lapse in consciousness accompanied by rapid eye blinking, lip smacking, and minor myoclonus of the upper extremities. Answer A refers to myoclonic seizures; therefore, it is incorrect. Answer B refers to tonic clonic, formerly known as grand mal, seizures; therefore, it is incorrect. Answer C refers to atonic seizures; therefore, it is incorrect.
A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
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Solution
Answer A is correct. A total mastectomy involves removal of the entire breast and some or all of the axillary lymph nodes. Following surgery, the client’s right arm should be elevated on pillows, to facilitate lymph drainage. Answers B, C, and D are incorrect because they would not help facilitate lymph drainage and would create increased edema in the affected extremity.