Nokea
The client is at highest risk for developing--------- evidenced by the client's--------
- A. Rheumatoid arthritis
- B. decreased Hct and Hgb levels
- C. ESR level
- D. Systemic lupus erythematosus
- E. Anemia evidenced by the client's
- F. Gout evidenced
- G. decreased WBC count
Correct Answer: D,G
Rationale: Decreased WBC count and elevated ESR suggest systemic lupus erythematosus.
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A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI(11) is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Smiles symmetrically
- C. Closes his eyes tightly
- D. Identifies a familiar scent
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the accessory nerve, controls the movement of the trapezius and sternocleidomastoid muscles, which are responsible for shoulder shrugging. By asking the client to shrug his shoulders, the nurse can assess the integrity of cranial nerve XI.
Choices B, C, and D are incorrect because they are associated with other cranial nerves. Smiling symmetrically is controlled by cranial nerve VII (facial nerve), closing eyes tightly is controlled by cranial nerve V (trigeminal nerve), and identifying a familiar scent is related to cranial nerve I (olfactory nerve).
Which of the following sites should the nurse use?
- A. Axillary
- B. Rectal
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The nurse should use the rectal site for temperature measurement as it provides the most accurate core body temperature reading. Rectal temperature closely reflects internal body temperature, making it the preferred site for assessing critically ill patients or infants who cannot cooperate for oral measurements. Axillary, oral, and tympanic sites may not accurately represent core body temperature due to external factors affecting the readings. Rectal temperature is the gold standard for accurate temperature measurement in certain clinical situations.
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A,C,F,G
Rationale: The correct answers (A, C, F, G) indicate potential prenatal complications. Urine protein (A) suggests preeclampsia, a serious condition characterized by high blood pressure (C) and proteinuria. Headaches (F) can also be a sign of preeclampsia. Gravida/parity (G) provides important obstetric history, identifying high-risk pregnancies. Fetal activity (B) and respiratory rate (E) are not specific to prenatal complications. Urine ketones (D) may indicate dehydration but not necessarily a prenatal complication.
Which of the following actions should the nurse plan to take?
- A. Place the clients head of bed flat
- B. apply heat to the client's abdomen
- C. keep the client on NPO status
- D. administer A laxative to the client
Correct Answer: C
Rationale: The correct answer is C: keep the client on NPO status. This is the correct action as it means "nothing by mouth," which is often necessary before certain medical procedures or surgeries to prevent aspiration. Choice A is incorrect as elevating the head of the bed reduces the risk of aspiration. Choice B is incorrect as heat application may not be indicated and could potentially worsen the client's condition. Choice D is incorrect as administering a laxative may not be appropriate without a proper assessment.
Which actions should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance.
- C. Report the findings to the appropriate authorities, following facility protocol.
- D. Take photographs of the injuries if permitted, as part of the documentation process.
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment.
Correct Answer: A,B,C,D,E
Rationale: The correct actions to address suspicion of elder abuse are A, B, C, D, and E.
A: Privately interviewing the client allows for open communication and confidentiality.
B: Documenting injuries in detail provides objective evidence for reporting and potential legal action.
C: Reporting findings to authorities is crucial to protect the elder and comply with legal obligations.
D: Taking photographs, if permitted, supports documentation and investigation.
E: Ensuring the client is not left alone with the suspected abuser protects the client during the assessment. Each action plays a crucial role in addressing elder abuse comprehensively.