Nokea
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?
- A. Muscle atrophy.
- B. Low grade fever.
- C. Joint pain.
- D. Hematuria.
Correct Answer: D
Rationale: Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.
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The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care?
- A. Ensure oral suction is available.
- B. Provide frequent mouth care.
- C. Keep the room at a comfortable temperature.
- D. Maintain the client in a semi-Fowler's position.
Correct Answer: A
Rationale: Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?
- A. Bronze pigmentation.
- B. Lower leg edema.
- C. Uneven hair distribution.
- D. Bounding peripheral pulse.
Correct Answer: C
Rationale: Uneven hair distribution, such as decreased hair growth, is indicative of compromised peripheral arterial circulation due to reduced blood flow to the area.
After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Right foot pale with sluggish capillary refill.
- B. Circumferential edema of right foot.
- C. Reports throbbing right leg pain.
- D. Increased temperature to lower extremity.
Correct Answer: A
Rationale: A pale right foot with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, requiring immediate intervention to prevent tissue damage.
Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
- A. Husky voice and troubled by hoarseness.
- B. Central type obesity, with thin extremities.
- C. Warm, soft, moist, salmon colored skin.
- D. Visible swelling of the neck, with no pain.
Correct Answer: B
Rationale: Central type obesity with thin extremities is a classic manifestation of Cushing's syndrome due to excess cortisol, causing fat accumulation in the trunk and muscle wasting in the extremities.
The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
- A. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
- B. Administer aspirin to prevent further clot formation and platelet clumping.
- C. Verify prescribed laboratory tests include prothrombin time and platelet count.
- D. Maintain elevated positioning of the dependent joints on affected side.
Correct Answer: A
Rationale: Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is essential for managing a suspected stroke, enabling time-sensitive interventions.