Nokea
A 4-year-old male is admitted to the unit with nephrotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:
- A. Apply ice to the scrotum
- B. Elevate the scrotum on a small pillow
- C. Apply heat to the abdominal area
- D. Administer an analgesic
Correct Answer: B
Rationale: Elevating the scrotum reduces edema by promoting fluid drainage, decreasing discomfort.
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The nurse is caring for a client whose native language is Korean; he speaks only a few words of English. The health care provider has determined that the client needs to undergo a coronary artery bypass graft. Which is the appropriate action by the nurse?
- A. ask the client's spouse to give consent for the procedure before explaining it to the client
- B. ask the client's spouse to translate for the health care provider and explain the procedure to the client
- C. communicate with the client by showing pictures of the intended surgery while a family member translates
- D. request a licensed translator to interpret for the health care provider and client during the conversation
Correct Answer: D
Rationale: A licensed translator ensures accurate communication and informed consent, adhering to ethical and legal standards.
The nurse is assessing a client with suspected glomerulonephritis. Which of the following findings would the nurse expect?
- A. Clear, pale urine.
- B. Hematuria and proteinuria.
- C. Polyuria and dilute urine.
- D. Absence of edema.
Correct Answer: B
Rationale: hematuria and proteinuria are hallmark signs of glomerulonephritis due to glomerular damage
The RN is making assignments on a 12-bed unit. Staff consists of one RN and two certified nursing assistants. Which client should be self-assigned?
- A. A client receiving decadron for emphysema
- B. A client with chest trauma and a new onset of hemoptysis
- C. A client with rib fractures and an O2 saturation of 93%
- D. A client 2 days post-operative lung surgery with a pulse oximetry of 92%
Correct Answer: B
Rationale: New-onset hemoptysis in a chest trauma client indicates potential serious complications (e.g., pulmonary hemorrhage) requiring RN assessment and intervention.
A client's lab results have just come in. The nurse reviews the electrolytes and contacts the health care provider regarding which result?
- A. chloride 167 mEq/L
- B. calcium 9.3 mg/dL
- C. phosphate 3.8 mg/dL
- D. sodium 141 mEq/L
Correct Answer: A
Rationale: Chloride 167 mEq/L is severely elevated (normal 98-106 mEq/L), requiring immediate attention. Other values are normal.
Which type of behavior modification is most likely to benefit a client who has a severe phobia regarding spiders?
- A. Positive reinforcement
- B. Negative reinforcement
- C. Desensitization
- D. Aversion therapy
Correct Answer: C
Rationale: Desensitization (C), gradually exposing the client to spiders, is most effective for phobias. Other methods (A, B, D) are less specific.