Nokea
A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client's balance? Select all.
- A. Romberg test
- B. Heel-to-toe walk
- C. Snellen test
- D. Spinal accessory function
- E. Rosenbaum test
Correct Answer: A, B
Rationale: The correct tests to assess balance are the Romberg test and heel-to-toe walk. The Romberg test evaluates proprioception and balance by having the client stand with feet together and eyes closed. If the client sways, it indicates balance impairment. The heel-to-toe walk assesses gait and balance by asking the client to walk in a straight line placing the heel of one foot in front of the toes of the other foot. Choices C, D, and E are incorrect as they are not related to balance assessment. The Snellen test evaluates visual acuity, spinal accessory function assesses shoulder movement, and Rosenbaum test measures near vision acuity.
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A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? Select all.
- A. Instruct the client not to use the Valsalva maneuver
- B. Apply elastic stockings
- C. Review lab values for total protein level
- D. Place pillows under the client's knees & lower extremities
- E. Assist the client to change position often
Correct Answer: B, E
Rationale: The correct answers are B and E. Applying elastic stockings helps promote circulation and prevent stasis, reducing the risk of thrombus formation. Assisting the client to change position often prevents prolonged immobility, which can lead to blood pooling and clot formation. Choice A is incorrect because the Valsalva maneuver can increase intra-abdominal pressure, potentially leading to venous stasis and thrombus formation. Choice C is irrelevant to thrombus prevention. Placing pillows under the client's knees and lower extremities (choice D) may promote comfort but does not directly reduce thrombus risk.
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? Select all.
- A. Urinary incontinence
- B. Diarrhea
- C. Bradypnea
- D. Orthostatic hypotension
- E. Nausea
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E. Opioid analgesics can cause respiratory depression (bradypnea), leading to shallow breathing. Orthostatic hypotension is a potential side effect due to vasodilation. Nausea is common with opioid use as they can stimulate the chemoreceptor trigger zone. Urinary incontinence (A) and diarrhea (B) are not typically associated with opioid analgesics. So, the nurse should anticipate monitoring for bradypnea, orthostatic hypotension, and nausea as potential adverse effects.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to assistive personnel (AP)?
- A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
- B. Reinforcing teaching w/a client who is learning to walk using a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely delegated to assistive personnel (AP). This task involves a straightforward procedure that does not require advanced nursing skills or critical thinking. The nurse can provide clear instructions and oversee the AP's performance.
Choice A is incorrect because feeding a client with aspiration pneumonia requires close monitoring by a nurse due to the risk of complications. Choice B is incorrect as reinforcing teaching for a client learning to walk with a quad cane involves assessing the client's understanding and progress, which is within the nurse's scope. Choice D is incorrect because applying a sterile dressing to a pressure ulcer requires sterile technique and assessment of wound healing, which should be done by a nurse.
A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development?
- A. Becoming actively involved in providing guidance to the next generation
- B. Adjusting to major changes in roles and relationships due to losses
- C. Devoting a great deal of time to establishing an occupation
- D. Finding oneself 'sandwiched' in between & being responsible for two generations
Correct Answer: C
Rationale: The correct answer is C: Devoting a great deal of time to establishing an occupation. This is an example of appropriate psychosocial development for a young adult as per Erikson's theory of psychosocial development. During the stage of young adulthood, individuals focus on establishing their careers and personal identities. This is a crucial developmental task during this stage, as it helps individuals gain a sense of purpose and direction in life. Choices A, B, and D involve responsibilities and challenges more commonly associated with other stages of life, such as middle adulthood or late adulthood. Therefore, they are not appropriate examples of psychosocial development for a young adult.
An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all.
- A. Extremes in age
- B. Impaired circulation
- C. Impaired/suppressed immune system
- D. Malnutrition
- E. Poor wound care
Correct Answer: B, C
Rationale: The correct answers are B (Impaired circulation) and C (Impaired/suppressed immune system). Impaired circulation can lead to decreased oxygen and nutrient delivery to the wound site, hindering the healing process. In this case, the adolescent may have impaired circulation due to diabetes mellitus. An impaired/suppressed immune system can also delay wound healing by impairing the body's ability to fight off infection and promote tissue repair. The other options are not applicable in this scenario: A (Extremes in age) does not apply as the client is an adolescent; D (Malnutrition) is not indicated as the client is tolerating a regular diet; and E (Poor wound care) is not evident as the incision is well-approximated and free of redness, with only scant serous drainage.