Nokea
A client is admitted with a possible bowel obstruction. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. Tell me about your pain.'
- B. What does your vomit look like?'
- C. Describe your usual diet.'
- D. Have you noticed an increase in abdominal size?'
Correct Answer: C
Rationale: Diet history is less directly related to diagnosing a bowel obstruction compared to pain, vomiting characteristics, or abdominal distension, which are hallmark symptoms.
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The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
- A. Reluctance to swallow
- B. Drooling of blood-tinged saliva
- C. An axillary temperature of 99°F
- D. Respiratory stridor
Correct Answer: D
Rationale: Respiratory stridor post-tonsillectomy indicates airway obstruction, a life-threatening complication requiring immediate reporting.
The nurse is interviewing a client with clinical depression. Which of the following risk factors would the nurse expect to find in the client's history? Select all that apply.
- A. normal childhood
- B. family history of depression
- C. recent major life change
- D. Lipitor used to treat high blood pressure
Correct Answer: B, C
Rationale: Family history of depression and recent major life changes are known risk factors for clinical depression. A normal childhood is not a risk factor, and Lipitor treats cholesterol, not blood pressure.
The nurse is caring for a 72-year-old female who must remain on bed rest after a hip fracture. The client has become confused and disoriented over the past 2 days. Which of the following is the best nursing intervention?
- A. placing familiar objects such as family photos, a clock, and a personal calendar on the wall
- B. asking the physician to order restraints so the client does not try and get up
- C. asking the client's daughter to stay overnight so the client is comforted by a familiar face
- D. moving the client to a better staffed floor, so she can be watched more carefully
Correct Answer: A
Rationale: Familiar objects like photos, clocks, and calendars help reorient a confused client, reducing disorientation safely. Restraints are a last resort, and the other options are less effective.
Skeletal traction is applied to the right femur of a client injured in a fall. The primary purpose of the skeletal traction is to:
- A. Realign the tibia and fibula
- B. Provide traction on the muscles
- C. Provide traction on the ligaments
- D. Realign femoral bone fragments
Correct Answer: D
Rationale: Skeletal traction for a femoral injury aims to realign femoral bone fragments, promoting proper healing and preventing deformity.
The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:
- A. Peanuts, dates, raisins
- B. Figs, chocolate, eggplant
- C. Pickles, salad with vinaigrette dressing, beef
- D. Milk, cottage cheese, ice cream
Correct Answer: C
Rationale: Vinaigrette may contain alcohol, which reacts with disulfiram, causing severe symptoms.