Nokea
A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Poor skin turgor
- B. Bradycardia
- C. Hypotension
- D. Pale yellow urine
- E. Flat neck veins
Correct Answer: A,C,E
Rationale: Poor skin turgor, hypotension, and flat neck veins indicate dehydration due to fluid loss. Bradycardia is incorrect; tachycardia is expected. Pale yellow urine suggests adequate hydration.
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A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?
- A. Provide the client with a high fiber diet.
- B. Administer a soap-suds enema to cleanse the colon.
- C. Allow the perineal area to air dry after each stool.
- D. Apply an alcohol-free barrier to the perineal area after each stool.
Correct Answer: D
Rationale: An alcohol-free barrier protects the skin from irritation due to frequent stooling.
A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Bell's palsy is characterized by muscle distortion due to facial nerve paralysis, leading to asymmetry in facial expressions (A). Pain behind the ear may occur due to inflammation or compression of the facial nerve (B). Impaired taste can result from altered function of the chorda tympani nerve, affecting taste sensation on the anterior two-thirds of the tongue (E). Choices C, D, F, G are incorrect as hearing loss is not a typical feature of Bell's palsy (C), facial twitching is more characteristic of conditions like hemifacial spasm (D), and there are no specific findings associated with F and G in Bell's palsy.
A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?
- A. Restrain the client as soon as seizure activity begins.
- B. Keep the lights on when the client is sleeping.
- C. Keep the client's bed in the lowest position.
- D. Have a padded tongue depressor available at the bedside.
Correct Answer: C
Rationale: The correct answer is C: Keep the client's bed in the lowest position. This is important for client safety during a seizure as it reduces the risk of injury from falling out of bed. Keeping the bed low ensures a shorter fall distance and minimizes the impact. Restraint (choice A) is not recommended as it can lead to further injury during a seizure. Keeping lights on (choice B) can trigger seizures in some individuals. Having a padded tongue depressor available (choice D) is not relevant to seizure precautions.
A nurse is observing an assistive personnel (AP) who is preparing to deliver a meal tray to a client who practices Orthodox Judaism. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?
- A. Allow the AP to deliver the food tray to the client.
- B. Call the dietary department and ask for a kosher meal tray.
- C. Replace the nonfat milk with apple juice.
- D. Explain to the client that he needs the protein in the milk and the beef.
Correct Answer: B
Rationale: Orthodox Jewish dietary laws prohibit consuming dairy and meat together, so a kosher meal should be requested.
A provider prescribes isometric exercises for a client who has a knee injury. The nurse should instruct the client to expect which of the following results from completing these exercises regularly?
- A. Increased muscle strength and tone to reduce muscle wasting
- B. Muscle hypertrophy to compensate for decreased joint strength
- C. Promotion of venous stasis to reduce the risk of embolus formation
- D. Reduction in bone density loss to prevent osteoporosis
Correct Answer: A
Rationale: The correct answer is A: Increased muscle strength and tone to reduce muscle wasting. Isometric exercises involve muscle contraction without joint movement, which helps improve muscle strength and tone. This is crucial in preventing muscle wasting commonly seen in clients with knee injuries. Muscle hypertrophy (B) is more associated with resistance training, not isometric exercises. Promotion of venous stasis (C) is incorrect as isometric exercises actually promote circulation and reduce the risk of blood clots. Reduction in bone density loss (D) is not directly related to isometric exercises.