Nokea
A client comes to the clinic reporting chronic low back pain. He asks the nurse to recommend specific exercises for him. Which of the following activities should the nurse suggest?
- A. Tennis
- B. Canoeing
- C. Swimming
- D. Archery
Correct Answer: C
Rationale: The correct answer is C: Swimming. Swimming is a low-impact exercise that helps strengthen the muscles in the back and core without putting excessive strain on the spine. It also promotes flexibility and improves cardiovascular health, which can aid in managing chronic low back pain. Other options like A (Tennis), B (Canoeing), and D (Archery) involve movements that may exacerbate back pain due to potential twisting, impact, or strain on the back muscles. Therefore, swimming is the most suitable recommendation for the client to alleviate and manage chronic low back pain effectively.
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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 is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?
- A. Inability to regulate body temperature
- B. Bradycardia
- C. Visual disturbances
- D. Inability to perceive sound
Correct Answer: A
Rationale: The correct answer is A: Inability to regulate body temperature. The hypothalamus plays a crucial role in regulating body temperature. Surgery near this area can disrupt its function, leading to potential problems in thermoregulation. The nurse should monitor the client for signs of hyperthermia or hypothermia. Bradycardia (choice B) is more related to dysfunction in the cardiovascular system, not typically affected by surgery near the hypothalamus. Visual disturbances (choice C) and inability to perceive sound (choice D) are more associated with areas of the brain responsible for processing sensory information, not specifically linked to the hypothalamus.
A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
- A. Cool skin
- B. Bradycardia
- C. Urine output 20 mL/hr
- D. Sodium 142 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Urine output 20 mL/hr. In dehydration, the body tries to conserve water, leading to decreased urine output. This finding indicates the body's attempt to retain fluids. A: Cool skin is incorrect as dehydration often presents with warm, dry skin due to decreased sweating. B: Bradycardia is unlikely in dehydration as the body tries to maintain cardiac output by increasing heart rate. D: A normal sodium level of 142 mEq/L does not specifically indicate dehydration.
A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?
- A. Cool skin
- B. Numbness
- C. Pallor
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. Thrombophlebitis is inflammation of a vein with a blood clot, leading to impaired blood flow. Edema, or swelling, is a common symptom due to the obstruction of blood flow. This results in fluid accumulation in the affected area. Cool skin, numbness, and pallor are not typical findings in thrombophlebitis. Cool skin and numbness are more indicative of nerve or circulation issues, while pallor suggests reduced blood flow but is not a common finding in thrombophlebitis.
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
- A. Wrap the blood pressure cuff snugly around the arm.
- B. Place the client's arm above the level of the heart.
- C. Check the instrument gauge to ensure the reading starts at zero.
- D. Center the cuff bladder over the brachial artery.
Correct Answer: B
Rationale: The correct answer is B because placing the client's arm above the level of the heart can result in an inaccurate blood pressure reading. Ideally, the arm should be at heart level to obtain an accurate measurement. A: Wrapping the cuff snugly ensures an accurate reading. C: Checking the gauge for zero ensures proper calibration. D: Centering the cuff bladder over the brachial artery is correct for accurate measurement. Overall, maintaining the arm at heart level is crucial to obtaining an accurate blood pressure reading.