Nokea
A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
- A. Assessing the skin daily for breakdown
- B. Massaging any erythematous areas on the skin
- C. Changing incontinence pads as soon as they become soiled with urine or feces
- D. Performing range-of-motion exercises and turning and repositioning the client
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning enhances blood flow to tissues, reducing the risk of pressure ulcers by relieving pressure points. Assessing skin (A) is monitoring, not an intervention to improve perfusion. Massaging erythematous areas (B) can worsen tissue damage. Changing pads (C) prevents irritation but doesn’t directly improve perfusion.
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Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
- A. Vitamin C and zinc
- B. Folic acid and niacin
- C. Vitamin A and biotin
- D. Thiamine and pyroxidine
Correct Answer: D
Rationale: Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine.
The client is prescribed warfarin (Coumadin). Which food should the nurse instruct the client to limit?
- A. Spinach
- B. Apples
- C. Chicken
- D. Rice
Correct Answer: A
Rationale: Spinach is high in vitamin K, which antagonizes warfarin’s anticoagulant effect, potentially reducing its efficacy. Apples, chicken, and rice have negligible vitamin K.
The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
- A. Prevent headaches
- B. Boost coagulation
- C. Prevent cerebral anoxia
- D. Decrease platelet aggregation
Correct Answer: D
Rationale: Aspirin reduces platelet aggregation, preventing clot formation in transient ischemic attacks, reducing stroke risk. It does not prevent headaches, boost coagulation, or directly prevent anoxia.
A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:
- A. Encourage him to drink plenty of fluids
- B. Expect him to have nausea with vomiting
- C. Keep him awake for the next 12 hours
- D. Wake him up every 1-2 hours during the night
Correct Answer: D
Rationale: If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.
Which of the following is a classic manifestation of glomerulonephritis?
- A. Hypertension
- B. Lassitude
- C. Fatigue
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: Hypertension is a classic manifestation of glomerulonephritis due to fluid retention and renal dysfunction. Lassitude and fatigue may occur but are less specific and vomiting/diarrhea are not typical.