Nokea
A client who is post-operative from a bowel resection is experiencing abdominal distention and pain. The nurse notices the client has not passed gas or had a bowel movement. What should the nurse assess first?
- A. The client's bowel sounds.
- B. The client's fluid intake.
- C. The client's pain level.
- D. The client's surgical incision.
Correct Answer: A
Rationale: Assessing bowel sounds is crucial in this situation as it helps determine if the client's gastrointestinal tract is functioning properly. Absent or hypoactive bowel sounds can indicate an ileus, a common post-operative complication. Assessing fluid intake (Choice B) is important but should come after assessing bowel sounds. Pain assessment (Choice C) is essential but addressing the physiological issue should take precedence. Checking the surgical incision (Choice D) is relevant but not the priority when the client is experiencing abdominal distention and potential gastrointestinal complications.
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An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the nurse?
- A. No bowel movement for two days
- B. Mother assists child in changing positions
- C. Weights are touching the foot of the bed
- D. Child is able to move the toes freely when tickled
Correct Answer: C
Rationale: The correct answer is C. In 90-90 traction, the weights should hang freely and not touch the foot of the bed to maintain proper traction and bone alignment. Option A is not necessarily a concern as bowel movements can be influenced by various factors, including diet changes and pain medication. Option B indicates good caregiver involvement, promoting comfort and preventing complications. Option D demonstrates neurovascular function, which is a positive finding. Therefore, the weights touching the foot of the bed is the finding that requires immediate attention to ensure the effectiveness of the traction.
In which type of cardiomyopathy does septal involvement occur?
- A. Congestive
- B. Dilated
- C. Hypertrophic
- D. Restrictive
Correct Answer: C
Rationale: Septal involvement is a characteristic feature of hypertrophic cardiomyopathy, where the septal wall of the heart thickens. This thickening can obstruct blood flow out of the heart, leading to complications such as arrhythmias and heart failure. This differentiates it from other types of cardiomyopathy. In congestive cardiomyopathy (choice A), the heart's chambers become enlarged and weakened, but there is no specific mention of septal involvement. Dilated cardiomyopathy (choice B) involves dilation and impaired contraction of the heart chambers, not specifically septal thickening. Restrictive cardiomyopathy (choice D) is characterized by stiffening of the heart muscle, affecting its ability to fill properly, without direct involvement of the septum.
All of the following are posture and body alignment problems EXCEPT:
- A. Kyphosis
- B. Scoliosis
- C. Thrombosis
- D. Lumbar lordosis
Correct Answer: C
Rationale: Thrombosis is a condition involving blood clots and is not related to posture or body alignment, unlike kyphosis, scoliosis, and lumbar lordosis, which are spinal alignment issues. Kyphosis refers to excessive outward curvature of the spine, scoliosis is characterized by a sideways curvature of the spine, and lumbar lordosis involves an exaggerated inward curve in the lower back. Thrombosis, on the other hand, is a condition where blood clots form in the blood vessels, not a posture or body alignment problem.
A male client attends a community support program for mentally impaired and chemically abusing clients. The client tells the PN that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client?
- A. Hypertension
- B. Hepatitis
- C. Glaucoma
- D. Diabetes
Correct Answer: B
Rationale: The correct answer is B: Hepatitis. Hepatitis is the greatest health risk for this client due to the potential for contracting the disease through needle-sharing, common among drug users. This can lead to serious liver complications. While hypertension, glaucoma, and diabetes are all important health concerns, they are not directly associated with the drug abuse mentioned in the scenario.
While caring for a client with an AV fistula in the left forearm, the nurse observed a palpable buzzing sensation over the fistula. What action should the nurse take?
- A. Loosen the dressing of the fistula
- B. Report the presence of a bounding pulse
- C. Document that the fistula is intact
- D. Apply gentle pressure over the site
Correct Answer: C
Rationale: The correct answer is C: Document that the fistula is intact. The palpable buzzing sensation (known as a thrill) over the AV fistula indicates proper functioning. It is essential for the nurse to document this finding to ensure ongoing monitoring of the fistula's status. Choices A, B, and D are incorrect. Choice A is incorrect because there is no indication to loosen the dressing. Choice B is incorrect as a bounding pulse is not associated with the palpable buzzing sensation of a thrill. Choice D is incorrect as applying pressure over the site is not necessary for this situation.