Nokea
A client post-mastectomy is concerned about the risk of lymphedema. What should the nurse include in the discharge instructions to minimize this risk?
- A. Wear compression garments on the affected arm.
- B. Avoid venipunctures and blood pressure measurements on the affected arm.
- C. Perform vigorous exercises to strengthen the affected arm.
- D. Keep the affected arm elevated at all times.
Correct Answer: B
Rationale: To minimize the risk of lymphedema after a mastectomy, it is essential to instruct the client to avoid venipunctures and blood pressure measurements on the affected arm. These procedures can lead to trauma or impede lymphatic flow, increasing the risk of lymphedema. Wearing compression garments helps manage lymphedema but is not preventive. Performing vigorous exercises can strain the affected arm and increase the risk of lymphedema. Keeping the affected arm elevated at all times is unnecessary and not an effective preventive measure against lymphedema.
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The practical nurse is caring for a client whose urine drug screen is positive for cocaine. Which behavior is this client likely to exhibit during cocaine withdrawal?
- A. Elevated energy level
- B. Euphoria
- C. High self-esteem
- D. Powerful craving for more
Correct Answer: D
Rationale: The correct answer is D: Powerful craving for more. During cocaine withdrawal, individuals often experience intense cravings for the drug, along with symptoms such as fatigue, depression, and anxiety. These cravings can be overpowering and lead to a strong desire to seek out more cocaine to alleviate the withdrawal symptoms. Choices A, B, and C are incorrect as elevated energy level, euphoria, and high self-esteem are more associated with the effects of cocaine rather than withdrawal symptoms. Withdrawal from cocaine is characterized by the opposite, such as fatigue, low mood, and intense cravings.
A client presents to the office with complaints of swelling in the legs, chills, and shortness of breath. During auscultation of the chest, a heart murmur is heard. The client's blood culture reveals a microorganism in the blood. When a microorganism is found in the blood, this condition is called
- A. Bacteremia
- B. Sepsis
- C. Septicemia
- D. Parasitic infection
Correct Answer: A
Rationale: When a microorganism is found in the blood, this condition is called bacteremia, which refers to the presence of bacteria in the bloodstream, as indicated by a positive blood culture. If not appropriately treated, bacteremia can progress to septicemia, also known as sepsis. Sepsis is a severe and life-threatening response to an infection, characterized by systemic inflammation and organ dysfunction. Parasitic infections involve pathogens other than bacteria and are not directly related to the scenario described.
A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the nurse plan to include in the child's plan of care?
- A. Recommend parents bring favorite snacks
- B. Encourage ambulation daily to the playroom
- C. Measure blood pressure every 4 to 6 hours
- D. Offer a selection of fresh fruit for each meal
Correct Answer: C
Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. Monitoring blood pressure frequently is crucial in managing glomerulonephritis, as hypertension is a common complication during the acute edematous phase. Choice A is incorrect as it does not address the specific needs of a child with glomerulonephritis. Choice B is incorrect as excessive activity may not be suitable during the acute phase, as rest and monitoring are more important. Choice D is incorrect as the focus should be on monitoring vital signs rather than meal options.
A nurse is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the nurse document in the medical record?
- A. Altered thought processes
- B. Impaired social interaction
- C. Risk for self-directed violence
- D. Disturbed thought processes
Correct Answer: D
Rationale: The correct answer is D: Disturbed thought processes. Echolalia, or the repetition of words, is indicative of disturbed thought processes, a common symptom in clients with schizophrenia. Choice A (Altered thought processes) is a more appropriate term than 'Disturbed thought processes' to describe the issue of echolalia. Choice B (Impaired social interaction) is not the best option in this scenario as echolalia is not primarily a social interaction issue. Choice C (Risk for self-directed violence) is not directly related to the symptom described in the question, which is echolalia, indicating a disturbance in thought processes.
The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, 'Why did this happen to my child? I just can't cope with this.' How should the PN respond?
- A. Ask her to share how the injury occurred to her child.
- B. Recommend that she remain calm and positive for her child.
- C. Express that the present situation must be overwhelming.
- D. Determine if someone else can help her cope with this tragedy.
Correct Answer: C
Rationale: Expressing empathy and acknowledging the mother's feelings helps in providing emotional support during a difficult time. This response validates her emotions and offers a comforting presence. Choice A is not appropriate as it focuses on gathering information rather than addressing the mother's emotional distress. Choice B may come off as dismissive of the mother's feelings and oversimplifies the complexity of the situation. Choice D shifts the responsibility to someone else instead of offering immediate support and comfort.