Nokea
A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?
- A. Elevate the affected leg on a pillow.
- B. Apply a warm compress to the affected leg.
- C. Perform passive range-of-motion exercises on the affected leg.
- D. Encourage the client to ambulate frequently.
Correct Answer: A
Rationale: The correct intervention for a client with a history of deep vein thrombosis (DVT) and unilateral leg swelling is to elevate the affected leg on a pillow. Elevating the affected leg helps reduce swelling and pain by promoting venous return and preventing stasis of blood flow. Applying a warm compress (Choice B) may increase inflammation and worsen the condition. Performing passive range-of-motion exercises (Choice C) and encouraging ambulation (Choice D) can dislodge a clot and lead to potential embolism, making these choices contraindicated in a client with DVT.
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When examining sources for funding, which criteria should the nurse clarify about the program for the community group?
- A. a prescription from the healthcare provider for each visit made
- B. documentation of a skilled care service provided during the visit
- C. a copy of the client's health history and social security card
- D. a record of the preventive healthcare services provided during the visit
Correct Answer: C
Rationale: The correct answer is C because when seeking funding sources for a community outreach program, it is essential to clarify aspects related to the client's personal information, such as health history and identification details. This information helps in demonstrating the need for the program and understanding the target population. Choices A, B, and D are incorrect because they focus on clinical documentation, services provided during visits, and preventive healthcare services, which are not directly related to clarifying funding criteria about the program.
A client with a history of seizures is admitted with status epilepticus. Which medication should the nurse prepare to administer?
- A. Phenytoin (Dilantin)
- B. Diazepam (Valium)
- C. Lorazepam (Ativan)
- D. Carbamazepine (Tegretol)
Correct Answer: C
Rationale: In the management of status epilepticus, the initial medication of choice is a benzodiazepine to rapidly terminate the seizure activity. Lorazepam (Ativan) is preferred over Diazepam (Valium) due to its longer duration of action and lower risk of respiratory depression. Phenytoin (Dilantin) and Carbamazepine (Tegretol) are not the first-line agents for the acute treatment of status epilepticus, making them incorrect choices in this scenario.
The healthcare provider is inspecting the external eye structures of a client. Which finding is a normal racial variation?
- A. Blue sclerae.
- B. Brown macules on the sclerae.
- C. Slightly yellow sclerae in an African-American client.
- D. Conjunctival pallor.
Correct Answer: C
Rationale: The slightly yellow color of the sclera is a normal racial variation found in the African-American population. Blue sclerae (Choice A) are associated with osteogenesis imperfecta, not a normal racial variation. Brown macules on the sclerae (Choice B) may indicate issues like melanoma or melanosis but are not a normal racial variation. Conjunctival pallor (Choice D) suggests anemia or decreased blood flow but is not a normal racial variation.
An elderly client with limited mobility reports feeling isolated and lonely. Which intervention should the nurse prioritize?
- A. Arrange for regular visits from a home health aide
- B. Suggest the client join a local senior center
- C. Refer the client to a support group for seniors
- D. Recommend that the client engage in a new hobby
Correct Answer: B
Rationale: The correct answer is to suggest the client join a local senior center. Joining a local senior center provides the elderly client with opportunities for social interaction, engagement in activities, and access to support systems, which can significantly help alleviate feelings of isolation and loneliness. Regular visits from a home health aide (Choice A) may provide physical assistance but may not address the client's need for social connection. Referring the client to a support group for seniors (Choice C) is beneficial, but joining a senior center offers a wider range of activities and social opportunities. Recommending a new hobby (Choice D) may be helpful, but the priority should be addressing the client's immediate need for social interaction and support.
The healthcare provider is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which intervention is most important?
- A. Restrict fluids to 1,000 mL per day.
- B. Administer a vasopressin antagonist.
- C. Monitor intake and output.
- D. Encourage a high-sodium diet.
Correct Answer: B
Rationale: Administering a vasopressin antagonist is the most critical intervention for a client with SIADH. SIADH is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. A vasopressin antagonist helps manage the symptoms by blocking the effects of ADH, promoting water excretion, and restoring electrolyte balance. Restricting fluids (choice A) may exacerbate hyponatremia, monitoring intake and output (choice C) is important but not the most critical intervention, and encouraging a high-sodium diet (choice D) is contraindicated in SIADH due to the risk of worsening hyponatremia.