Evaluation
Question 1 of 5.
The nurse has given the client information about the use of sublingual nitroglycerin tablets prescribed for as-needed use if chest pain occurs. Which client statement helps assure the nurse that the client understands how to self-administer the medication?
A. I will keep the nitroglycerin in a shirt pocket close to my body.
B. I won't take the medication until the chest pain actually begins and intensifies.
C. If I get a headache when I first start taking the nitroglycerin, then I will take an aspirin.
D. I will discard unused nitroglycerin tablets 3 to 6 months after the bottle is opened, and obtain a new prescription.
Explanation: Nitroglycerin may be self-administered sublingually 5 to 10 minutes before an activity that triggers chest pain. Tablets should be discarded 3 to 6 months after opening the bottle (per expiration date), and a new bottle of pills should be obtained from the pharmacy. Nitroglycerin is unstable and is affected by heat and cold, so it should not be kept close to the body (warmth) in a shirt pocket; rather, it should be kept in a jacket pocket or a purse. Headache often occurs with early use and diminishes in time. Acetaminophen may be used to treat headache.
Question 2 of 5.
A client who had a laryngectomy for laryngeal cancer has started oral intake. The nurse determines that the first stage of dietary advancement has been tolerated when the client ingests which type of diet without aspirating or choking?
A. Bland
B. Full liquids
C. Clear liquids
D. Semisolid foods
Explanation: Oral intake after laryngectomy is started with semisolid foods. When the client can manage this type of food, liquids may be introduced. A bland diet is not appropriate. The client may not be able to tolerate the texture of some of the solid foods that would be included in a bland diet. Thin liquids are not given until the risk of aspiration is negligible.
Question 3 of 5.
An older client is a victim of elder abuse. He and his family have been attending counseling sessions for the past month. Which statement, made by the abusive family member, would indicate an understanding of more positive coping skills?
A. I will be more careful to make sure that my father's needs are 100 \% met.
B. I am so sorry and embarrassed that the abusive event occurred. It won't happen again.
C. I feel better equipped to care for my father now that I know where to turn if I need assistance.
D. Now that my father is going to move into my home with me, I will have to stop drinking alcohol.
Explanation: Elder abuse is sometimes caused by family members who are being expected to care for their aging parents. This care can cause the family to become overextended, frustrated, or financially depleted. Knowing where to turn in the community for assistance with caring for an aging family member can bring much-needed relief. Using these alternatives is a positive coping skill for many families. The rest of the options are statements of good faith or promises, which may or may not be kept in the future.
Question 4 of 5.
A 24-hour-old term infant had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up?
A. Weight loss of 4 ounces and dry, peeling skin
B. Blood glucose level of 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) before the last feeding
C. Breast-feeding for 20 minutes or more, with strong sucking
D. High-pitched cry, drinking 10 to 15mL of formula per feeding
Explanation: Hypoglycemia causes central nervous system symptoms (high-pitched cry), and it is also exhibited by a lack of strength for eating enough for growth. At 24 hours old, a term infant should be able to consume at least 1 ounce of formula per feeding. A high-pitched cry is indicative of neurological involvement. Weight loss over the first few days of life and dry, peeling skin are normal findings for term infants. Blood glucose levels are acceptable at 40 \mathrm{mg} / \mathrm{dL}(2.28 \mathrm{mmol} / \mathrm{L}) during the first few days of life.
Question 5 of 5.
A home care nurse visits a child with a diagnosis of celiac disease. Which finding best indicates that a gluten-free diet is being maintained and has been effective?
A. The child is free of diarrhea.
B. The child is free of bloody stools.
C. The child tolerates dietary wheat and rye.
D. A balanced fluid and electrolyte status is noted on the laboratory results.
Explanation: Watery diarrhea is a frequent clinical manifestation of celiac disease. The absence of diarrhea indicates effective treatment. Bloody stools are not associated with this disease. The grains of wheat and rye contain gluten and are not allowed. A balance of fluids and electrolytes does not necessarily demonstrate the improved status of celiac disease.
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