Nokea
A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the health care provider because these changes are most consistent with which complication?
- A. Cardiogenic shock
- B. Cardiac tamponade
- C. Pulmonary embolism
- D. Dissecting thoracic aortic aneurysm
Correct Answer: A
Rationale: Progressive hypotension and tachycardia (BP 140/88 to 88/58, pulse 92 to 118) suggest cardiogenic shock post-MI.
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Which intervention should the nurse implement to help toughen the residual limb of a client with a right AKA?
- A. Push residual limb against pillow
- B. Apply elastic bandage around residual limb
- C. Apply vitamin B12 to surgical incision
- D. Elevate residual limb three times a day
Correct Answer: B
Rationale: Elastic bandages shape and toughen the residual limb, preparing it for prosthesis.
The client diagnosed with male pattern baldness is prescribed finasteride. When should the nurse evaluate for effectiveness of the medication?
- A. After the client has been taking the medication for 1 month.
- B. When the client states there are no hair strands in the comb.
- C. At the time the client's hair changes texture and color.
- D. One year after taking the hair growth stimulant medication daily.
Correct Answer: D
Rationale: Finasteride requires up to 1 year to assess hair regrowth (effective in 50% of cases). One month is too soon, comb findings and texture/color changes aren't reliable indicators.
It is documented that a patient has superficial partial-thickness burns over both anterior lower arms. What should the nurse expect when assessing this patient?
- A. Dry with no blisters
- B. Waxy appearance and cherry red in color
- C. Dry leathery appearance and pale or brown in color
- D. Open or closed blisters, mild edema, easily blanches
Correct Answer: D
Rationale: Superficial partial-thickness burns involve the epidermis and part of the dermis, typically presenting with blisters, mild edema, and blanching due to preserved capillary refill.
Which of the following is a major function of the skin?
- A. Excretion of wastes
- B. Vitamin C synthesis
- C. Temperature regulation
- D. Prevention of dehydration
Correct Answer: C
Rationale: Functions of the skin include protection from the environment, temperature regulation, prevention of dehydration, excretion of waste products, and vitamin D synthesis (not C). This question was restructured from a multiple-response format to focus on a key function, with temperature regulation selected as a representative correct answer.
The nurse is caring for a client in a hip spica cast. Which intervention should the nurse include in the plan of care?
- A. Assess the client's popliteal pulses every shift.
- B. Elevate the leg on pillows and apply ice packs.
- C. Teach the client how to ambulate with a tripod walker.
- D. Assess the client for distention and vomiting.
Correct Answer: D
Rationale: Distention and vomiting can indicate cast syndrome or bowel obstruction, critical to monitor in a hip spica cast.