Nokea
Physical examination of a client regarding mobility status should:
- A. begin with gait.
- B. be oriented to time, place, and person.
- C. begin with the Romberg test.
- D. begin with the Tandem Walk test.
Correct Answer: A
Rationale: Gait is usually assessed as the client walks into the room. Normal gait is smooth, flowing, and rhythmic without assistive devices.
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A client's postoperative pain seems to be getting worse instead of better. When the nurse asks the client, 'Why do you think it's getting worse?' the client replies, 'My wife died last month. It's all I can think about.' The nurse must now consider:
- A. calling the physician for an increased dosage of pain medication
- B. calling the physician for a sedative
- C. referring the client for a psychiatric consult
- D. developing interventions for grief and loss
Correct Answer: D
Rationale: The client's grief over his wife's death is likely exacerbating his pain perception, requiring grief and loss interventions to address the affective component.
A 15 year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?
- A. Lab values of Potassium and Sodium
- B. Lab values of glucose and hemoglobin
- C. ECG
- D. CT scan
Correct Answer: A
Rationale: Diuretics can disturb the sodium and potassium balance, resulting in cardiac complications. Monitoring electrolyte levels is critical.
The client is in skeletal traction with 20 lb of traction applied to a right lower leg fracture. Which intervention should the nurse perform at regular intervals?
- A. Perform pin site care
- B. Remove the weights
- C. Reposition the right leg
- D. Perform passive ROM to the legs
Correct Answer: A
Rationale: A: Regular pin site care prevents infection. B: Weights are only removed in emergencies. C: Repositioning disrupts alignment. D: ROM is avoided to maintain traction.
The nurse is assessing the female client who is 65 inches tall and has a small body frame. Based on the information in the chart illustrated, what is the client's approximate ideal body weight?
Correct Answer: 117
Rationale: Height is 5'5†(65/ 12 = 5 remainder 5). Formula: 105 lb for 5 ft + 5 lb × 5 = 130 lb. Small frame subtracts 10% (130 × 0.1 = 13 lb). 130 − 13 = 117 lb.
To remove hard contact lenses from an unresponsive client, the nurse should:
- A. gently irrigate the eye with an irrigating solution from the inner canthus outward.
- B. grasp the lens with a gentle pinching motion.
- C. don sterile gloves before attempting the procedure.
- D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.
Correct Answer: D
Rationale: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.