Nokea
A client is being monitored for transient ischemic attacks. She is oriented, can open her eyes spontaneously, and follows commands. What is her Glasgow Coma Scale score?
Correct Answer: 15
Rationale: The Glasgow Coma Scale assesses eye opening (4 for spontaneous), verbal response (5 for oriented), and motor response (6 for following commands). The client's score is 4 + 5 + 6 = 15.
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An appropriate nursing intervention for a client with fatigue related to cancer treatment includes teaching the client to:
- A. Increase fluid intake.
- B. Minimize naps or periods of rest during day.
- C. Conserve energy by limiting activities.
- D. Limit dietary intake of high-fiber foods.
Correct Answer: C
Rationale: Conserving energy by limiting activities helps manage fatigue, a common side effect of cancer treatment, by balancing rest and activity.
The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation?
- A. Heart rate 57 bpm
- B. SpO2 of 94% on room air
- C. Blood pressure in 1 mm/s
- D. Ankle brachial index of 0.65
Correct Answer: D
Rationale: An ankle-brachial index (ABI) of 0.65 is significantly below the normal range (0.9–1.3), indicating potential peripheral vascular disease (PVD) due to arterial insufficiency. This finding warrants further evaluation, especially given the client's symptoms of claudication (pain during exercise relieved by rest) and smoking history, which are risk factors for PVD. The other options€”heart rate, SpO2, and blood pressure€”are either normal or irrelevant in this context.
A client at risk for lung cancer asks why he is scheduled for a computed tomography (CT) scan as part of his initial workup. The nurse's best response is which of the following?
- A. CT is far superior to magnetic resonance imaging for evaluating lymph node metastasis.
- B. CT is noninvasive and readily available.
- C. CT is useful for distinguishing small differences in tissue density and detecting nodal involvement.
- D. CT can distinguish a malignant from a nonmalignant adenopathy.
Correct Answer: C
Rationale: CT scans are valuable in lung cancer workups because they can detect small differences in tissue density and identify nodal involvement, aiding in staging and diagnosis.
To approach a deaf client, the nurse should do which of the following first?
- A. Knock on the room's door loudly.
- B. Close and open the vertical blinds rapidly.
- C. Talk while walking into the room.
- D. Get the client's attention.
Correct Answer: D
Rationale: Getting the client's attention first (e.g., by waving or tapping gently) ensures effective communication with a deaf client, as they may not hear auditory cues.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 2 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
For each client finding below, click to specify if the finding is consistent with the disease process of heat exhaustion or heat stroke. Each finding may support more than 1 disease process.
- A. Temperature 105° F (40.5° C)
- B. Confusion
- C. Perspiration
- D. Tachycardia
- E. Signs of dehydration
- F. Hypotension
Correct Answer: A,B,C,D,E,F
Rationale: A (Heat Stroke), B (Heat Stroke), C (Heat Exhaustion), D (Both), E (Both), F (Both). Temperature 104°F and confusion are hallmark signs of heat stroke. Perspiration is typical in heat exhaustion but absent in heat stroke. Tachycardia, dehydration, and hypotension occur in both conditions due to heat stress.