Nokea
The nurse is caring for a client with suspected acute rheumatic fever. Which of the following questions would be most important for the nurse to ask the client?
- A. Do you typically take all of your antibiotics when they are prescribed?
- B. Has anyone in your family had rheumatic fever?
- C. What has your temperature been over the past several days?
- D. Have you recently had a streptococcal throat infection?
Correct Answer: D
Rationale: Recent streptococcal infection (D) is the primary trigger for rheumatic fever, making it the most important question. Antibiotic compliance (A), family history (B), and fever (C) are relevant but less critical.
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The nurse is with a client with obsessive-compulsive disorder who counts backwards several times each day. Which of the following statements by the client would indicate an improvement in the client's condition? Select all that apply.
- A. I take a short, brisk walk to decompress when I begin to feel anxious.
- B. My neighbor goes grocery shopping for me because I get anxious and begin counting.
- C. Having a stressful job worsens my anxiety, but I use deep-breathing exercises to manage it.
- D. Counting helps me cope with my anxiety. It does not hurt anyone, and it is better than drinking alcohol.
- E. I used to start counting as soon as I boarded the bus, but now I can ride the bus for 30 minutes without counting.
Correct Answer: A,C,E
Rationale: Statements A, C, and E indicate improvement as the client uses adaptive coping strategies (walking, deep breathing) and reports reduced compulsive behavior (delayed counting). Statement B shows reliance on others, and D justifies the compulsion, both indicating no improvement.
The nurse is caring for a client who is recovering from a cerebrovascular accident and is partially paralyzed on the right side. How should the nurse position the chair when getting the client out of bed?
- A. On the right side of the bed facing the foot of the bed
- B. On the right side of the bed facing the head of the bed
- C. On the left side of the bed facing the foot of the bed
- D. On the left side of the bed facing the head of the bed
Correct Answer: C
Rationale: Placing the chair on the left (unaffected) side facing the foot allows the client to pivot using their stronger side, facilitating safe transfer. Right-side placement or incorrect orientation hinders mobility.
The nurse is talking with a client who is scheduled for cardiac catheterization. Which of the following findings would be essential to follow up? Select all that apply.
- A. elevated serum C-reactive protein level
- B. previous allergic reaction to IV contrast
- C. prolonged PR interval on ECG
- D. received metformin today for type 2 diabetes mellitus
- E. elevated serum creatinine
Correct Answer: B,D,E
Rationale: Allergy to contrast (B), recent metformin use (D), and elevated creatinine (E) increase risks during cardiac catheterization (anaphylaxis, lactic acidosis, and renal injury). CRP (A) and PR interval (C) are less urgent.
An adult is scheduled for a paracentesis. What should the nurse plan to do immediately before the procedure is started?
- A. Give the client a full glass of water
- B. Have the client empty his/her bladder
- C. Ask the client to empty his/her bowels
- D. Administer diazepam (Valium) as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Water intake, bowel emptying, or sedation are not immediate pre-procedure priorities.
Which of the following situations is most likely to produce sepsis in the neonate?
- A. Maternal diabetes
- B. Prolonged rupture of membranes
- C. Cesarean delivery
- D. Precipitous vaginal birth
Correct Answer: B
Rationale: Prolonged rupture of membranes. Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.