79) ANSWER

 D)  Suggesting communication strategies

RATIONALE

Since Alzheimer''s disease is a progressive chronic illness that greatly challenges caregivers, the nurse can be of greatest assistance in helping family to identify language changes, and select verbal and nonverbal communication strategies to minimize aberrant behavior. 

78) ANSWER

Correct Answer: 4, 5, 3, 2, 1

RATIONALE

4. The nurse must first determine the

infant’s responsiveness by thumping the

baby’s feet.

5. The nurse should then open the child’s

airway using the head-tilt chin-lift technique,

with care taken not to hyperextend

the neck. Then the nurse should look,

listen, and feel for respirations.

3. The nurse then administers quick puffs of

air while covering the child’s mouth and

nose, preferably with a rescue mask.

2. The nurse should determine whether the

infant has a pulse by checking the brachial

artery.

1. If the infant has no pulse, the nurse should

begin chest compressions using two fingers

at a rate of 30:2.

77) ANSWER

D) Encourages fluid intake of 2,500-3,000 mL daily, since it is not contraindicated by other client conditions.

RATIONALE

Agents for herpes virus as herpes zoster can be nephritic. Important interventions include monitoring renal function and ensuring good hydration to decrease toxic effects. This drug is not reported to be particularly hepatotoxic (option 1). Sexual intercourse is to be avoided if the client is being treated with the acylovir for genital herpes (option 2). Insomnia is not a side effect of acyclovir (option 3). In order to select the correct answer to this question, recall that the medication is toxic to the kidneys. Knowing this, be directed to option 4. The other answers do not apply to nephrotoxicity.

76) ANSWER

A) Recognizing hemorrhage

RATIONALE

The cause of bleeding in a client with esophageal varices is usually rupture, which is a medical emergency. The hemorrhage that occurs is usually frank bleeding such as vomiting of copious amounts of dark-colored blood. The nurse should be able to recognize signs of hemorrhage (tachycardia, hypotension, low platelets, and hematocrit and hemoglobin H & H). Think of hemorrhage associated with esophageal varices.

75) ANSWER

B) "Cromolyn limits inflammation, and therefore bronchoconstriction, with exposure to an allergen."

RATIONALE

Cromolyn is a nonsteroidal agent that stabilizes mast cells so bronchoconstrictive and inflammatory substances are not released when stimulated with an allergen. It is used to treat inflammation of the airway. It does not cause bronchoconstriction (option 4), and is not a bronchodilator (option 1) or expectorant (option 3). Use medication knowledge and the process of elimination to make a selection.

74) ANSWER

C) when the edges roll up and exudate leaks.

RATIONALE

Transparent film dressings on a clean, noninfected wound can be left in place for days, until the seal is broken, exudate leaks out, or the edges roll up. Older adults are at risk for skin breakdown. A nurse needs knowledge of what dressings are chosen and when they are changed. Consider the choices; when there are similarities, some choices can be eliminated.

73) ANSWER

B) Pepto-Bismol

RATIONALE

Pepto-Bismol (bismuth salicylate), is contraindicated in clients who are allergic to aspirin or salicylates. The other medications can be given to the client safely. Knowing the compositions of the medications will lead to the correct answer. Realizing that salicylate refers to aspirin, as is listed in the question stem, will lead to the only correct answer that contains aspirin, option 2.