Nokea
A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present
- A. Temperature of 99.5 degrees Fahrenheit with painful urination
- B. An open, reddened wound on the heel
- C. Insomnia and daytime fatigue
- D. Nausea with 2 episodes of vomiting
Correct Answer: B
Rationale: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.
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While sitting at the nurse's station, the nurse observes that a client uses a tissue to pick up magazines and change channels on the television. There has been no such behavior in the past. The nurse should:
- A. Talk with the client about the behavior.
- B. Provide the client with a pair of nonsterile gloves.
- C. Take the tissues away from the client.
- D. Recognize the behavior as a means of getting attention.
Correct Answer: A
Rationale: Talking with the client assesses potential obsessive-compulsive behavior or anxiety. Gloves or removing tissues may escalate distress. Attention-seeking is an assumption without evidence.
The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply.
- A. Family history of skin cancer
- B. High number of moles
- C. History of severe adolescent acne
- D. Immunosuppressant medication use
- E. Outdoor occupation
Correct Answer: A,B,D,E
Rationale: Risk factors for skin cancer include family history , high number of moles , immunosuppressant use increasing susceptibility, and outdoor occupation due to UV exposure. Severe acne is not a direct risk factor unless associated with specific treatments like radiation.
The nurse is collecting data on a client who has arrived at the clinic for pregnancy confirmation and prenatal evaluation. Which of the following findings indicate diagnostic evidence (positive signs) of pregnancy? Select all that apply.
- A. Cervical softening upon examination
- B. Fetal heart tones detected by Doppler device
- C. Positive serum human chorionic gonadotropin test
- D. Report of fetal movement felt by client
- E. Visualization of fetus via ultrasound
Correct Answer: B,E
Rationale: Positive signs of pregnancy are objective, provider-verified findings: fetal heart tones by Doppler and ultrasound visualization . Cervical softening and hCG test are probable signs, and fetal movement is subjective.
The nurse is caring for a client who had surgery yesterday. When administering omeprazole, the client asks 'What is that for? I don't take it at home.' Which reply by the nurse is most appropriate?
- A. Omeprazole helps prevent nausea by making your stomach empty faster.'
- B. Omeprazole helps prevent you from developing an ulcer due to the stress of surgery.'
- C. Omeprazole protects you from getting an infection while on antibiotics.'
- D. This medication will treat your gastroesophageal reflux disease (GERD).'
Correct Answer: B
Rationale: Omeprazole is a proton pump inhibitor used postoperatively to prevent stress ulcers due to surgical stress. It does not affect gastric emptying , prevent infections , or assume GERD without a diagnosis.
The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention?
- A. Administer oxygen via nasal cannula for client comfort and safety
- B. Clean area with povidone iodine in a circular motion moving outward
- C. Hold the child with the head and knees tucked in and the back rounded out
- D. Monitor and record vital signs every 15 minutes throughout the procedure
Correct Answer: C
Rationale: During a lumbar puncture for an infant, holding the child in a flexed position with head and knees tucked and back rounded ensures proper spinal alignment for safe needle insertion. Oxygen is not routinely needed, cleaning is typically done by the provider, and vital sign monitoring is important but not the primary intervention.