Nokea
A client has sustained second- and third-degree burns over her entire left arm and posterior trunk. Using the Rule of Nines, which percentage of the client's body is burned?
- A. 9%
- B. 18%
- C. 27%
- D. 36%
Correct Answer: C
Rationale: Per the Rule of Nines, one arm is 9% and the posterior trunk is 18%, totaling 27% body surface area burned.
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The nurse is performing a neurological assessment on a client post right cerebral vascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention?
- A. Decrease in level of consciousness
- B. Loss of bladder control
- C. Altered sensation of stimuli
- D. Emotional lability
Correct Answer: A
Rationale: Decrease in level of consciousness. A further decrease in the level of consciousness would be indicative of a further progression of the CVA.
The nurse is talking with the parent of a 1-day-old newborn who had a circumcision using the plastic ring method. Which of the following statements by the parent would require follow-up?
- A. I will contact the health care provider if bleeding does not stop with gentle pressure
- B. I should avoid using alcohol-based cleansing wipes during diaper changes
- C. I need to leave the device in place and allow it to fall off on its own
- D. I understand that yellow exudate on the area is a sign of infection
Correct Answer: D
Rationale: Yellow exudate is normal during circumcision healing, not a sign of infection, requiring further teaching. Contacting the provider for persistent bleeding, avoiding alcohol wipes, and leaving the device are correct.
A client with schizophrenia is experiencing auditory hallucinations and is admitted for evaluation and treatment. A suitable activity for a client with schizophrenia who is experiencing auditory hallucinations is:
- A. Watching a movie with other clients
- B. Working on a large-piece puzzle
- C. Playing a game of solitaire
- D. Taking a walk with the nurse
Correct Answer: D
Rationale: Taking a walk with the nurse provides distraction and support, reducing focus on hallucinations. Group activities or solitary tasks (B, C) may be overwhelming or less therapeutic.
The nurse is reinforcing teaching with a client who has a prescription for sertraline for the treatment of depression. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I can discontinue the medication as soon as I start feeling better
- B. I should avoid eating aged cheeses, cured meats, or pickled foods
- C. I should expect to feel better within 2 to 3 days after starting this medication
- D. I will report any thoughts of self-harm to my health care provider
Correct Answer: D
Rationale: Reporting self-harm thoughts is critical, as sertraline may increase suicide risk initially. Discontinuing abruptly risks relapse, food restrictions apply to MAOIs, and benefits take weeks, not days.
A client is admitted with pernicious anemia. The client reports all of the following. Which is most likely related to the admitting diagnosis?
- A. I often have diarrhea.'
- B. My tongue is more red and thick than usual.'
- C. I have little bruise-like spots on my arms and legs.'
- D. I have been running a fever for the last two days.'
Correct Answer: B
Rationale: Pernicious anemia, due to vitamin B12 deficiency, often causes a sore, red, beefy tongue. Diarrhea, bruising, or fever are less specific.