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A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the following should the nurse include as a risk factor for osteoporosis?
- A. Early menopause
- B. History of falls
- C. African American race
- D. Obesity
Correct Answer: A
Rationale: The correct answer is A: Early menopause. A client who goes into early menopause, from natural or surgical causes, is at a greater risk for developing osteoporosis due to the rapid drop in estrogen levels. Choice B, history of falls, is not a direct risk factor for osteoporosis but rather a risk for fractures related to osteoporosis. Choice C, African American race, is actually associated with a lower risk of osteoporosis. Choice D, obesity, is considered a protective factor against osteoporosis as excess weight can provide additional support to bones.
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A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?
- A. Eat three large meals daily
- B. Consume high-calorie foods
- C. Limit caffeinated drinks to two per day
- D. Drink fluids during meal time
Correct Answer: B
Rationale: The correct answer is B: 'Consume high-calorie foods.' Clients with COPD often have increased energy needs due to the work of breathing. Consuming high-calorie, high-protein foods can help provide the necessary energy and prevent weight loss. Choice A is incorrect because eating three large meals daily may lead to increased shortness of breath due to a full stomach putting pressure on the diaphragm. Choice C is incorrect because caffeinated drinks can contribute to dehydration, which is not ideal for clients with COPD. Choice D is incorrect because drinking fluids during mealtime can cause bloating and early satiety, making it difficult for clients to consume enough calories.
A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?
- A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
- B. Administer oxygen to a client who has an oxygen saturation of 91%
- C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
- D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery
Correct Answer: B
Rationale: The priority intervention is administering oxygen. Postoperatively, the client's oxygen saturation should be at or above 95%. Oxygen is essential for tissue perfusion and cellular oxygenation. While managing pain is important, oxygenation takes precedence. Instructing a client about coughing and deep breathing exercises is important for preventing respiratory complications but is not as urgent as addressing low oxygen saturation. Initiating an infusion of 0.9% sodium chloride is a routine postoperative intervention for fluid balance but is not the priority when oxygen saturation is low.
A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?
- A. Flail chest
- B. Hemothorax
- C. Pulmonary contusion
- D. Pneumothorax
Correct Answer: A
Rationale: The correct answer is A: Flail chest. Flail chest results from multiple rib fractures, causing paradoxical chest movement where the injured part moves inward during inspiration and outward during expiration, interfering with ventilation. Choice B, Hemothorax, involves blood in the pleural cavity and does not typically cause paradoxical chest movement. Choice C, Pulmonary contusion, is a bruise to the lung tissue and does not present with paradoxical chest movement. Choice D, Pneumothorax, is the presence of air in the pleural space, leading to lung collapse, but it does not demonstrate paradoxical chest movement like in flail chest.
A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?
- A. Inspect the pin site every 4 hours
- B. Monitor the client's skin under the halo vest
- C. Ensure two personnel hold the halo device when repositioning the client
- D. Apply powder to the client's skin under the vest to decrease itching
Correct Answer: B
Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.
A client is scheduled for an electroencephalogram (EEG) and a nurse is providing teaching. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should not wash my hair prior to the procedure.
- B. I will receive a sedative 1 hour before the procedure.
- C. I should avoid eating prior to the procedure.
- D. I will be exposed to flashes of light during the procedure.
Correct Answer: D
Rationale: The correct answer is D. The nurse should inform the client that flashes of light or pictures are often used during the procedure to assess the brain's response to stimuli. Choices A, B, and C are incorrect because washing hair, receiving a sedative, and avoiding eating are not directly related to the EEG procedure.