Nokea
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
- A. Loss of sensation in the lower extremities
- B. Back pain that lessens when standing
- C. Decreased urinary output
- D. Pulsations in the periumbilical area
Correct Answer: D
Rationale: A pulsatile mass in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding aorta.
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Acticoat (silver nitrate) dressings are applied to the legs of a client with deep partial thickness burns. The nurse should:
- A. Change the dressings once per shift
- B. Moisten the dressing with sterile water
- C. Change the dressings only when they become soiled
- D. Moisten the dressing with normal saline
Correct Answer: B
Rationale: Acticoat dressings require moistening with sterile water to activate the silver release, which provides antimicrobial effects for burn wounds.
A pediatric client is admitted to the hospital for treatment of diarrhea caused by an infection with salmonella. Which of the following most likely contributed to the child's illness?
- A. Brushing the family dog
- B. Playing with a turtle
- C. Taking a pony ride
- D. Feeding the family cat
Correct Answer: B
Rationale: Turtles are common carriers of Salmonella, which can be transmitted to children through handling, leading to gastrointestinal infection.
According to Maslow's hierarchy of needs, order the following needs from most basic to most advanced (bottom of the pyramid to the top):
- A. safety and security
- B. esteem
- C. physiological
- D. love and belonging
- E. self-actualization
Correct Answer: C,A,D,B,E
Rationale: Maslow’s hierarchy: physiological (most basic), safety and security, love and belonging, esteem, self-actualization (most advanced).
A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:
- A. Have a Protime done monthly
- B. Eat more fruits and vegetables
- C. Drink more liquids
- D. Avoid crowds
Correct Answer: A
Rationale: Monthly Protime tests monitor the therapeutic effect of warfarin and prevent bleeding complications.
The nurse is caring for a client receiving peritoneal dialysis. Which of the following assessment findings would require an intervention by the nurse?
- A. Abdominal discomfort during infusion of dialysate.
- B. Presence of constipation.
- C. Cloudy dialysate output.
- D. Ecchymosis around peritoneal catheter.
Correct Answer: C
Rationale: indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity