Nokea
Which nursing question would elicit the most thorough assessment data regarding the client's recent sleeping patterns?
- A. Are you sleeping well at home?
- B. Did you get much sleep last night?
- C. May we talk about how you've been sleeping?
- D. Do you think you get enough sleep on a nightly basis?
Correct Answer: C
Rationale: Option 3 is a question and provides the client the opportunity to express thoughts and feelings. The remaining options could lead to a one-word answer that would not provide thorough assessment data. Additionally, one night of sleep may not tell the nurse how the pattern has been over time.
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A clinic nurse is caring for a client with a suspected diagnosis of gestational hypertension. The nurse assesses the client, expecting to note which set of findings if gestational hypertension is present?
- A. Edema, ketonuria, and obesity
- B. Edema, tachycardia, and ketonuria
- C. Glycosuria, hypertension, and obesity
- D. Elevated blood pressure and proteinuria
Correct Answer: D
Rationale: Gestational hypertension is the most common hypertensive disorder in pregnancy. It is characterized by the development of hypertension and proteinuria. Glycosuria and ketonuria occur in diabetes mellitus. Tachycardia and obesity are not specifically related to diagnosing gestational hypertension. Edema is not specific to gestational hypertension and can occur in many disorders.
The nurse is reviewing the antenatal history of several clients in early labor. The nurse recognizes which factor documented in the history as having the potential for causing neonatal sepsis after delivery? Select all that apply.
- A. Of Asian heritage
- B. Two previous miscarriages
- C. Prenatal care began during the 3rd trimester
- D. History of substance abuse during pregnancy
- E. Dietary assessment identified poor eating habits
- F. Spontaneous rupture of membranes 24 hours ago
Correct Answer: C,D,E,F
Rationale: Risk factors for neonatal sepsis can arise from maternal, intrapartal, or neonatal conditions. Maternal risk factors before delivery include a history of substance abuse during pregnancy, low socioeconomic status, and poor prenatal care and nutrition. Premature rupture of the membranes or prolonged rupture of membranes greater than 18 hours before birth is also a risk factor for neonatal acquisition of infection. There is no research to associate heritage or previous miscarriages to the development of neonatal sepsis.
The nurse is assessing a client diagnosed with pleurisy 48 hours ago. When auscultating the chest the nurse is unable to detect the pleural friction rub, which was auscultated on admission. This change in the client's condition confirms which event has occurred?
- A. The prescribed medication therapy has been effective.
- B. The client has been taking deep breaths as instructed.
- C. The effects of the inflammatory reaction at the site decreased.
- D. There is now an accumulation of pleural fluid in the inflamed area.
Correct Answer: D
Rationale: Pleurisy is the inflammation of the visceral and parietal membranes. These membranes rub together during respiration and cause pain. Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. Options 1, 2, and 3 are incorrect interpretations.
The nurse prepares to transfer the client with a newly applied arm cast into the bed using which method?
- A. Placing ice on top of the cast
- B. Supporting the cast with the fingertips only
- C. Asking the client to support the cast during transfer
- D. Using the palms of the hands and soft pillows to support the cast
Correct Answer: D
Rationale: The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this would be done after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.
The nurse is caring for a client who was recently admitted with a diagnosis of anorexia nervosa. When the nurse enters the room, the client is engaged in rigorous push-ups. Which nursing action should the nurse implement?
- A. Allowing the client to complete the exercise program
- B. Interrupting the client and weigh the client immediately
- C. Interrupting the client and offer to take the client for a walk
- D. Telling the client that he or she is not allowed to exercise rigorously
Correct Answer: C
Rationale: Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise, as well as place limits on rigorous activities. Allowing the client to complete the exercise program could be harmful. Weighing the client reinforces the altered self-concept that the client experiences and the client's need to control weight. Telling the client that he or she is not allowed to exercise rigorously will increase his or her anxiety.