Nokea
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention?
- A. increased restlessness
- B. tachycardia
- C. tracheal deviation
- D. tachypnea
Correct Answer: C
Rationale: tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.
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A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes. She sits for hours rocking back and forth and appears to be talking to someone at intervals. She does not eat or bathe or relate to others. How should the nurse approach this client upon admission?
- A. Explain the unit routines to her in detail
- B. Ask her if she has any question about the unit or what she is supposed to do
- C. Briefly explain the most essential information and then sit with her
- D. Take her by the hand and orient her to the unit
Correct Answer: C
Rationale: A withdrawn client may be overwhelmed by detailed explanations. Brief information and quiet presence build trust and reduce anxiety.
An adult client is showing signs of developing hypovolemic shock. Which finding is most likely to be present?
- A. Elevated systolic and lowered diastolic blood pressure
- B. Decreased heart rate
- C. Decreased urine output
- D. Decreased respiratory rate
Correct Answer: C
Rationale: Hypovolemic shock reduces circulating volume, decreasing renal perfusion and causing oliguria (decreased urine output). Blood pressure typically narrows, heart rate increases, and respiratory rate rises.
A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply.
- A. Contact the clinic if any hot areas or foul odors develop in the cast
- B. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet
- C. Elevate the affected extremity above heart level for the first 48 hours
- D. Expect some numbness and tingling of the fingers during the first week
- E. Use only soft, padded objects to scratch the skin under the cast
Correct Answer: A,B,C,E
Rationale: Hot areas or odors (A) suggest infection, keeping the cast dry (B) prevents skin breakdown, elevation (C) reduces swelling, and soft objects (E) avoid injury. Numbness and tingling (D) are not normal and may indicate nerve compression, requiring immediate reporting.
An adult who has cholecystitis reports clay-colored stools and moderate jaundice. The nurse knows that which is the best explanation for the presence of clay-colored stools and jaundice?
- A. There is an obstruction in the pancreatic duct.
- B. There are gallstones in the gallbladder.
- C. Bile is no longer produced by the gallbladder.
- D. There is an obstruction in the common bile duct.
Correct Answer: D
Rationale: Clay-colored stools and jaundice result from a common bile duct obstruction, preventing bile flow to the intestines and causing bilirubin buildup in the blood. The gallbladder stores, not produces, bile, and pancreatic or gallbladder issues are less directly related.
The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?
- A. Report a persistent cough to the health care provider
- B. The child can return to school in 4 days
- C. Administer chewable aspirin for pain
- D. The child may gargle with saline as necessary for discomfort
Correct Answer: A
Rationale: Report a persistent cough to the health care provider. Persistent coughing may indicate bleeding, which requires immediate attention.