Nursing Elites

1. The parents of a child on phenytoin (Dilantin) have received discharge instructions from the nurse. Which of the following statements suggests that the teaching was effective?

• A. We will call the healthcare provider if the child develops acne.
• B. Our child should brush and floss carefully after every meal.
• C. We will skip the next dose if vomiting or fever occurs.
• D. When our child is seizure-free for 6 months, we can stop the medication.

Correct answer: B

Rationale: The correct answer is B. Proper oral hygiene, including brushing and flossing carefully after every meal, is essential for children on phenytoin to prevent gingival hyperplasia, a common side effect. Choice A is incorrect because acne is not a common side effect of phenytoin and does not require immediate healthcare provider notification. Choice C is incorrect because vomiting or fever should not prompt skipping a dose without consulting the healthcare provider first. Choice D is incorrect because discontinuing phenytoin should never be done abruptly or without healthcare provider guidance, even if the child is seizure-free for 6 months.

2. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

• A. Bruising at the operative site
• B. Elevated heart rate
• C. Decreased platelet count
• D. No bowel movement for 3 days

Correct answer: D

Rationale: The correct answer is D. Constipation is a common side effect of Tylenol #3, which contains codeine. Codeine can slow down bowel movements, leading to constipation. Monitoring for constipation and implementing management strategies is crucial. Choices A, B, and C are incorrect because bruising at the operative site, elevated heart rate, and decreased platelet count are not commonly associated side effects of Tylenol #3.

3. A client underwent coronary artery bypass grafting and is learning about following a low-cholesterol diet. Which of the following food choices indicates the client's understanding of these dietary instructions?

• A. Liver
• B. Milk
• C. Beans
• D. Eggs

Correct answer: C

Rationale: The correct answer is C: Beans. Beans are an excellent choice for individuals following a low-cholesterol diet post-coronary artery bypass grafting due to their low cholesterol content. Beans are high in fiber and protein, making them a heart-healthy option. Choice A, Liver, is high in cholesterol and should be avoided in a low-cholesterol diet. Choice B, Milk, contains cholesterol and saturated fats, which are not ideal for this diet. Choice D, Eggs, are also high in cholesterol and should be limited in a low-cholesterol diet.

4. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

• A. Exercise by doing weight-bearing activities
• B. Exercise to reduce weight
• C. Avoid exercise activities that increase the risk of fracture
• D. Exercise to strengthen muscles and thereby protect bones

Correct answer: A

Rationale: The correct answer is A: Exercise by doing weight-bearing activities. Weight-bearing activities help strengthen bones and prevent further bone loss in clients with osteoporosis. This type of exercise includes activities like walking, dancing, and weightlifting, which help improve bone density. Choice B is incorrect because the primary focus should be on bone health, not weight reduction. Choice C is incorrect as avoiding all exercise activities that increase the risk of fracture can lead to muscle weakness and a decline in bone health. Choice D is also incorrect because while strengthening muscles is beneficial, the emphasis for osteoporosis management should be on weight-bearing exercises specifically.

5. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

• A. have the client identify coping methods
• B. get the description of the location and intensity of the pain
• C. accept the client's report of pain
• D. determine the client's status of pain

Correct answer: B

Rationale: The correct answer is B: 'get the description of the location and intensity of the pain.' When a client complains of pain, the initial step in pain assessment is to gather information about the location and intensity of the pain. This helps the nurse understand the nature of the pain and lays the groundwork for further assessment and management. Choice A is incorrect because identifying coping methods comes later in the assessment process. Choice C is incorrect as accepting the client's report of pain is important, but not the first step. Choice D is incorrect as determining the client's pain status also comes after gathering information about the pain.

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