Nokea
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
- A. Taking hourly blood pressures with mechanical cuff
- B. Encouraging fluid intake of at least 200 mL per hour
- C. Position in high Fowler's with knee gatch raised
- D. Administering Tylenol as ordered
Correct Answer: B
Rationale: Hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and to promote blood flow, reducing the risk of complications.
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A manic client is admitted to an inpatient psychiatric center. He is hyperactive, talking quickly, acting aggressively, and pacing. The nursing staff should
- A. outline realistic expectations for the client's behavior.
- B. ignore the client's behavior.
- C. allow the client to eat lunch with other clients to observe the interaction.
- D. assign an RN to stay with the client at all times.
Correct Answer: D
Rationale: A manic client’s behavior requires close supervision for safety. Assigning an RN to stay with the client ensures monitoring and intervention as needed.
A client with rheumatoid arthritis tells the nurse that she is having increasing difficulty cooking, cleaning, and attending to activities of daily living. Which of the following referrals is the most appropriate?
- A. Occupational therapist.
- B. Physical therapist.
- C. Home health agency.
- D. Assisted-living facility.
Correct Answer: A
Rationale: An occupational therapist (A) helps clients with rheumatoid arthritis adapt to difficulties with daily activities through adaptive techniques and equipment. Physical therapy (B), home health (C), or assisted living (D) may be secondary.
A client has been on prolonged bedrest following surgery. The nurse notes that the patient has pain in the right calf on palpation with dorsiflexion of the ankle. Which of the following causes does the nurse suspect?
- A. Arthritis
- B. Muscle strain
- C. Compartment syndrome
- D. Deep vein thrombosis
Correct Answer: D
Rationale: Calf pain with dorsiflexion (Homan's sign) suggests deep vein thrombosis (D), common after prolonged bedrest. Arthritis (A), muscle strain (B), and compartment syndrome (C) present differently.
The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet?
- A. Roasted chicken
- B. Noodles
- C. Cooked broccoli
- D. Custard
Correct Answer: C
Rationale: Cooked broccoli is high in fiber and should be avoided on a low-roughage diet for diverticulitis to prevent irritation.
As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?
- A. The baby is sleeping.
- B. The umbilical cord is compressed.
- C. There is head compression.
- D. There is uteroplacental insufficiency.
Correct Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency, reducing fetal oxygenation during contractions.