Nokea
Which question should the healthcare provider ask when assessing the client for an endocrine dysfunction?
- A. "Have you noticed any pain in your legs when walking?"
- B. "Have you had any unexplained weight loss?"
- C. "Have you noticed any change in your bowel movements?"
- D. "Have you experienced any joint pain or discomfort?"
Correct Answer: B
Rationale: The correct answer is B: "Have you had any unexplained weight loss?" Unexplained weight loss can be a significant symptom of various endocrine disorders, such as hyperthyroidism and diabetes. Weight changes are often closely linked to endocrine dysfunction due to the hormonal imbalances affecting metabolism. Choices A, C, and D are less specific to endocrine dysfunction. Pain in the legs, changes in bowel movements, and joint pain or discomfort are symptoms that can be related to various health conditions but are not as indicative of endocrine disorders as unexplained weight loss.
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When measuring the leg circumference of a client with bipedal edema, what position is best to ensure accurate measurements?
- A. Dorsal recumbent
- B. Sitting
- C. Standing
- D. Supine
Correct Answer: A
Rationale: When measuring the leg circumference of a client with bipedal edema, the best position to ensure accurate and consistent measurements is the dorsal recumbent position. This position allows the legs to be positioned comfortably, and the individual is lying on their back with legs extended, facilitating accurate measurement of the circumference without the influence of gravity. Sitting, standing, and supine positions may not provide optimal conditions for accurate leg circumference measurements, particularly in clients with bipedal edema where positioning and consistency are crucial. Sitting and standing positions may not allow for consistent leg positioning and could introduce errors due to the effects of gravity on the fluid distribution. The supine position, while similar to dorsal recumbent, may not be as comfortable for the client and could still be influenced by gravity when measuring leg circumference.
The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:
- A. Astride one of her hips
- B. Strapped in an infant seat
- C. Wrapped tightly in a blanket
- D. Under the arm using a football hold
Correct Answer: A
Rationale: Carrying the infant astride one of her hips helps keep the legs apart and can help reduce muscle tightness. This position allows for better support and alignment, preventing further muscle contractures. Strapping the infant in an infant seat, wrapping tightly in a blanket, or using the football hold under the arm would not provide the same benefits and may even exacerbate muscle tightness in a child with cerebral palsy.
When a patient is prescribed an oral anticoagulant, what should the nurse monitor for?
- A. Elevated blood glucose
- B. Decreased blood pressure
- C. Signs of bleeding
- D. Increased appetite
Correct Answer: C
Rationale: When a patient is prescribed an oral anticoagulant, the nurse should monitor for signs of bleeding. Oral anticoagulants work by inhibiting the blood's ability to clot, which increases the risk of bleeding. Monitoring for signs of bleeding such as easy bruising, petechiae, hematuria, or bleeding gums is crucial to prevent complications. Elevated blood glucose (Choice A) is not directly related to oral anticoagulant use. Decreased blood pressure (Choice B) is not a common effect of oral anticoagulants. Increased appetite (Choice D) is not a typical side effect of oral anticoagulants and is not a primary concern when monitoring a patient on this medication.
The nurse is preparing a postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?
- A. Establish a rapport with the client to decrease embarrassment during site assessment
- B. Encourage the client to lie in the lithotomy position twice a day
- C. Milk the tube inserted during surgery to facilitate the passage of flatus
- D. Digitally dilate the rectal sphincter to express old blood
Correct Answer: A
Rationale: Establishing rapport with the client is crucial in postoperative care to create a trusting relationship, reduce embarrassment, and enhance comfort during assessments. Encouraging the client to lie in the lithotomy position is not recommended after a hemorrhoidectomy as it can be uncomfortable and may disrupt wound healing. Milking the tube inserted during surgery is not a standard practice and could lead to complications. Digitally dilating the rectal sphincter is not indicated post-hemorrhoidectomy and can cause harm to the client.
Which instructions should the nurse discuss with the client diagnosed with Raynaud's phenomenon?
- A. Explain that exacerbations will not occur in the summer
- B. Use nicotine gum to help quit smoking
- C. Wear extra warm clothing during cold exposure
- D. Avoid prolonged exposure to direct sunlight
Correct Answer: C
Rationale: The correct instruction for a client diagnosed with Raynaud's phenomenon is to wear extra warm clothing during cold exposure. This is essential in preventing vasospasms triggered by cold temperatures, which can worsen symptoms of Raynaud's phenomenon. Choice A is incorrect because exacerbations can occur in any season. Choice B is irrelevant and not directly related to managing Raynaud's phenomenon. Choice D is also incorrect as sunlight exposure does not significantly impact Raynaud's phenomenon.