Nokea
A client has ataxia following a cerebral vascular accident. The nurse should:
- A. Supervise the client's ambulation
- B. Measure the client's intake and output
- C. Request a consult for speech therapy
- D. Provide the client with a magic slate
Correct Answer: A
Rationale: Ataxia impairs coordination, increasing fall risk, so supervising ambulation is essential for safety.
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A client has a rate-responsive permanent pacemaker in his upper chest. The nurse understands rate-responsive to mean which of the following?
- A. A pacemaker function prevents excessive changes in the pacing rate.
- B. The pacing rate increases above the normal pacing rate with sudden bradycardia.
- C. The pacemaker switches from atrial tracking mode to nontracking mode with atrial fibrillation.
- D. The pacing rate increases when the sensors note increased activity.
Correct Answer: D
Rationale: A rate-responsive pacemaker increases the pacing rate when sensors detect increased activity (D), mimicking normal heart rate response. Other options (A, B, C) describe different pacemaker functions.
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
- A. The client’s urine test is positive for glucose and acetone.
- B. The client has 1+ pedal edema in both feet at the end of the day.
- C. The client complains of an increase in vaginal discharge.
- D. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency
The nurse is assigned a male client with a long-term in-dwelling catheter for incontinence. The nurse plans on performing which of the following to prevent complications?
- A. perform perineal care using sterile technique
- B. irrigate daily with 60 cc normal saline
- C. restrict fluids to 1,500 cc/day
- D. stabilize the catheter on the abdomen
Correct Answer: D
Rationale: Stabilizing the catheter prevents traction and urethral trauma. Perineal care uses clean technique, routine irrigation is unnecessary, and fluid restriction is inappropriate.
The nurse is teaching a client with a new diagnosis of osteoporosis about lifestyle modifications. Which of the following recommendations should the nurse include?
- A. Avoid weight-bearing exercises.
- B. Limit calcium intake to 800 mg per day.
- C. Perform daily stretching exercises.
- D. Stop smoking and limit alcohol intake.
Correct Answer: D
Rationale: smoking cessation and limiting alcohol reduce bone loss and fracture risk in osteoporosis
The nurse is assessing a client with suspected meningitis. Which of the following findings would the nurse expect?
- A. Positive Kernig’s sign.
- B. Hypothermia.
- C. Soft, non-tender neck.
- D. Decreased level of consciousness.
Correct Answer: A
Rationale: positive Kernig’s sign (pain and resistance on leg extension) is a classic finding in meningitis