Nokea
A 38-year-old client who has mitral stenosis is hospitalized for a valve replacement. Which condition is the client most likely to report having had earlier in life?
- A. Meningitis
- B. Syphilis
- C. Rheumatic fever
- D. Rubella
Correct Answer: C
Rationale: Mitral stenosis is commonly a sequel of rheumatic fever, which damages heart valves. Meningitis, syphilis, and rubella are not typically associated with mitral valve pathology.
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A client 4 days post colostomy is preparing to be discharged home. Which findings are concerning and should be further investigated? Select all that apply.
- A. Client states, 'I will need home health to empty the pouch.'
- B. Client states, 'There is a little gas in the colostomy bag.'
- C. No bowel sounds are present and the client reports nausea
- D. Skin surrounding the stoma is red and excoriated
- E. Stoma is red, edematous, and smaller than the previous day
Correct Answer: C,D,E
Rationale: Absent bowel sounds with nausea suggest obstruction, red/excoriated skin indicates irritation, and a shrinking stoma may signal complications. Gas is normal, and needing home health is not inherently concerning.
The nurse is caring for a 6-year-old who is postoperative open right tibial fracture reduction with cast placement. Which finding requires priority action?
- A. Blood-tinged stain on the inner aspect of the cast
- B. Capillary refill of 2 seconds on the affected extremity
- C. Mild swelling of toes on the right foot
- D. Pain of 9/10 an hour after a dose of morphine
Correct Answer: D
Rationale: Severe pain (9/10) despite recent morphine suggests complications like compartment syndrome, requiring immediate action. Other findings are less urgent.
The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states:
- A. I will hold the cane in my right hand.
- B. I will advance the cane and the right leg together.
- C. I will be able to walk only by using a walker.
- D. I will hold the cane in my left hand.
Correct Answer: D
Rationale: For right-sided hemiplegia, the cane is held in the left hand to support the weaker right side. Holding it in the right hand or advancing it with the right leg is incorrect. A walker is not always necessary.
The nurse is talking with a client's spouse who insists on being present in the room while the client is receiving CPR. Which of the following actions should the nurse take?
- A. Call security to escort the spouse to the waiting room.
- B. Let the spouse stay and assign a staff member to explain the situation.
- C. Allow the spouse to stay in the room but out of sight of the resuscitation efforts.
- D. Inform the spouse that family members are not allowed in a client's room during emergency situations.
Correct Answer: B
Rationale: Allowing the spouse to stay with a staff member to explain reduces distress and supports family presence, which is often permitted during CPR.
The nurse is caring for a client who has a C6 spinal cord injury. He complains of blurred vision and a severe headache. His blood pressure is 210/140. What action should the nurse take initially?
- A. Check for bladder distention
- B. Place in Trendelenburg position
- C. Administer PRN pain medication
- D. Continue to monitor blood pressure
Correct Answer: A
Rationale: Symptoms and hypertension suggest autonomic dysreflexia, often triggered by bladder distention in spinal cord injury. Checking and relieving distention is the initial action.