Nokea
A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation?
- A. The ulcer has a pale-colored base.
- B. The ulcer is deep, with even edges.
- C. The ulcer has little granulation tissue.
- D. The ulcer has a brownish or 'brawny' appearance.
Correct Answer: D
Rationale: When assessing a venous stasis leg ulcer, the nurse should expect to note a brownish or 'brawny' appearance. This discoloration is often due to hemosiderin deposits. This characteristic finding helps differentiate venous stasis ulcers from other types of ulcers, making it crucial for accurate diagnosis and appropriate treatment.
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The client at risk for thrombophlebitis receives reinforcement from the LPN/LVN regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information?
- A. I should avoid sitting for prolonged periods.
- B. I will take frequent walks and avoid prolonged bed rest.
- C. I should drink plenty of fluids to stay hydrated.
- D. I will use compression stockings as advised by my doctor.
Correct Answer: B
Rationale: The correct answer is B. Taking frequent walks and avoiding prolonged bed rest are essential measures to promote circulation and reduce the risk of thrombophlebitis. Physical activity helps prevent blood from pooling and clotting in the veins, thus decreasing the likelihood of thrombophlebitis development.
The client is receiving intravenous heparin for treatment of a pulmonary embolism. Which medication should the nurse ensure is readily available?
- A. Protamine sulfate
- B. Vitamin K
- C. Calcium gluconate
- D. Magnesium sulfate
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is monitoring a client with left-sided heart failure. Which assessment finding indicates that the client's condition is worsening?
- A. Clear lung sounds
- B. Increased peripheral pulses
- C. Bibasilar crackles
- D. Improved activity tolerance
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations?
- A. I should take daily medication for life.
- B. I should eat a diet that is low in fat and cholesterol.
- C. I should continue to smoke to keep the metabolic rate high.
- D. I should begin to exercise if the diet is not sufficient to achieve weight loss.
Correct Answer: B
Rationale: Choosing a diet that is low in fat and cholesterol is crucial for managing and preventing the progression of coronary artery disease (CAD). This dietary change can help reduce the risk of further complications associated with CAD, such as plaque buildup in the arteries. It is a fundamental lifestyle alteration that can positively impact the client's heart health.
The healthcare professional is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. What should the healthcare professional do next?
- A. Ask whether the client wants to seek counseling or therapy.
- B. Explore with the client the sources of stress in their life.
- C. Reassure the client that stress is common in today's world.
- D. Ask the client to make a list of stressors for later evaluation.
Correct Answer: B
Rationale: It is important for the healthcare professional to explore the sources of stress with the client to develop an effective stress management plan tailored to the individual's specific stressors. This approach can help in identifying triggers, implementing appropriate interventions, and supporting the client's overall well-being.