Nokea
A nurse is caring for a client who has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement?
- A. Obtain a soft mattress for the client's bed.
- B. Position soft pillows against the bottom of the feet.
- C. Use a footboard to maintain dorsiflexion of the feet.
- D. Cross the client's legs at the ankles.
Correct Answer: C
Rationale: The correct answer is C: Use a footboard to maintain dorsiflexion of the feet. This is important for preventing foot drop, a common issue with right-sided paralysis post-CVA. By maintaining dorsiflexion, the nurse helps prevent contractures and promotes proper alignment of the feet. A soft mattress (A) does not address the specific issue of foot drop. Positioning soft pillows against the bottom of the feet (B) may not provide adequate support and dorsiflexion. Crossing the client's legs at the ankles (D) is contraindicated as it can lead to pressure ulcers and further complications.
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A nurse at a community health clinic is assisting with creating a brochure about testicular cancer. Which of the following information should the nurse include?
- A. Perform a testicular self-examination twice per year.
- B. Palpate the epididymis.
- C. Gently roll the testicles to feel for abnormalities.
- D. Use one hand to palpate the testicles.
Correct Answer: C
Rationale: The correct answer is C: Gently roll the testicles to feel for abnormalities. This is the most appropriate information to include in the brochure because gently rolling the testicles between the thumb and fingers is the recommended technique for testicular self-examination. By rolling the testicles, individuals can better detect any lumps or changes in texture that may indicate testicular cancer.
Choice A is incorrect because the current recommendation is to perform testicular self-exams monthly, not twice per year. Choice B is incorrect as palpating the epididymis is not part of the standard testicular self-examination procedure. Choice D is incorrect because using both hands is recommended for better examination.
A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?
- A. Assist the client back into bed and apply restraints.
- B. Call the family and ask them to make arrangements for someone to sit with the client.
- C. Check the client for injuries.
- D. Obtain a prescription for medication to sedate the client.
Correct Answer: C
Rationale: The correct answer is C: Check the client for injuries. This is the most appropriate action as it ensures the client's safety and well-being. By checking for injuries, the nurse can assess the extent of harm and provide necessary medical attention promptly. It also helps in determining if further interventions are required.
Choice A is incorrect because restraints should not be applied without proper assessment. Choice B is incorrect as the priority is to address the immediate physical needs of the client. Choice D is incorrect as sedation should not be the first response to a fall.
A nurse at a community-based health fair is promoting having a routine Papanicolaou test (Pap smear) to young adult women. Which of the following types of preventive care is the Pap smear?
- A. Primary level
- B. Secondary level
- C. Tertiary level
- D. Self-care ability level.
Correct Answer: B
Rationale: The correct answer is B: Secondary level preventive care. A Pap smear is a screening test that aims to detect precancerous or cancerous cells in the cervix at an early stage. This type of preventive care falls under secondary prevention because it focuses on early detection and treatment of disease before it progresses. Primary prevention (choice A) aims to prevent the disease from occurring in the first place. Tertiary prevention (choice C) focuses on managing and reducing the impact of the disease after it has already developed. Self-care ability level (choice D) is not a recognized level of preventive care.
A nurse is reviewing the medical record of a client who has pneumonia. The nurse should plan to have the client lie on his stomach in Trendelenburg position with pillows elevating the right side of his chest to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: D
Rationale: This positioning promotes drainage from the posterior right lower lobe by using gravity.
A nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is D, respiratory alkalosis. Hyperventilation causes excessive loss of carbon dioxide, leading to respiratory alkalosis. This is evidenced by lightheadedness, paresthesias, blurred vision, and confusion due to decreased carbon dioxide levels in the blood. Metabolic acidosis (A) is characterized by low pH and bicarbonate levels, not seen in this scenario. Metabolic alkalosis (B) is due to excess bicarbonate, which is not present in hyperventilation. Respiratory acidosis (C) is caused by retention of carbon dioxide, opposite of what is seen in hyperventilation.