Nokea
A client is experiencing chest pain. Which statement made by the client indicates angina rather than a myocardial infarction?
- A. "I became dizzy when I stood up."?
- B. "I was nauseated and began vomiting."?
- C. "The pain started in my chest and stopped after I sat down."?
- D. "The pain began with a migraine and progressed to numbness in my left arm."?
Correct Answer: B
Rationale: The correct answer is: '"The pain started in my chest and stopped after I sat down."? This statement suggests angina rather than a myocardial infarction because angina is typically triggered by exertion or stress and relieved by rest. Nausea and vomiting (Choice B) are more commonly associated with a myocardial infarction. Choices A and D are not typical symptoms of either angina or myocardial infarction.
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The nurse is teaching a community health class for cancer prevention and screening. Which individual has the highest risk for colon cancer?
- A. Client with irritable bowel syndrome
- B. Family history of colon polyps
- C. Client with cirrhosis of the liver
- D. History of colon surgery
Correct Answer: B
Rationale: A family history of colon polyps and/or colon cancer is a significant risk factor for developing colon cancer. Individuals with a family history are more likely to develop colon cancer due to genetic predisposition. While other factors like irritable bowel syndrome, cirrhosis of the liver, and history of colon surgery may contribute to an increased risk of colon cancer, having a family history of colon polyps is the highest risk factor. Irritable bowel syndrome does not directly increase the risk of colon cancer. Cirrhosis of the liver is associated with liver cancer rather than colon cancer. A history of colon surgery may reduce the risk of colon cancer in some cases by removing precancerous polyps.
The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice until the client regains full consciousness?
- A. Supine
- B. Fowlers
- C. Lateral
- D. High Fowlers
Correct Answer: C
Rationale: The correct answer is 'Lateral.' When a client is very drowsy or sedated, placing them in the lateral position is important to maintain an open airway and allow for drainage of secretions. This position helps prevent airway obstruction and aspiration.
Choice A, 'Supine,' is lying flat on the back and may not be ideal for a drowsy client due to the risk of airway compromise.
Choice B, 'Fowlers,' is a semi-sitting position that is beneficial for clients with respiratory distress, but it may not be the best choice for a very drowsy individual.
Choice D, 'High Fowlers,' is a more upright sitting position, which again may not be suitable for a drowsy client as it does not facilitate airway patency as effectively as the lateral position.
The nurse is caring for a client with full-thickness burns to the left arm and trunk. What is the priority for this client?
- A. Pain management
- B. Airway assessment
- C. Fluid volume status monitoring
- D. Risk for infection prevention
Correct Answer: C
Rationale: Correct! With full-thickness burns, there is a significant risk of fluid loss through the burn wound and fluid shift, leading to hypovolemia and shock. Monitoring and maintaining the client's fluid volume status is crucial to prevent complications like hypovolemic shock. Pain management (Option A) is essential but not the priority in this situation. While airway assessment (Option B) is crucial, it is typically assessed first in clients with respiratory distress. Preventing infection (Option D) is important but managing fluid volume status takes precedence in the initial care of a client with full-thickness burns.
What essential assessment must be performed for clients with implanted dialysis access devices?
- A. Color and capillary refill
- B. Patency and pulse
- C. Thrill and bruit
- D. Trousseau's and temperature
Correct Answer: C
Rationale: Correct! When assessing clients with implanted dialysis access devices, it is crucial to palpate for the thrill, which indicates blood flow, and auscultate for the bruit, a humming sound, to ensure the patency of the access device. Choices A, B, and D are incorrect as they are not specific assessments related to dialysis access devices. Checking color and capillary refill, pulse, Trousseau's sign, and temperature are important assessments in other contexts but not specifically for monitoring implanted dialysis access devices.
A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
- A. Aspiration noted on a honey-thick diet
- B. Pain felt during a bowel movement
- C. Pain felt in the left upper quadrant
- D. Right shoulder pain
Correct Answer: B
Rationale: The correct answer is 'Pain felt during a bowel movement.' Endoscopy is used to examine the upper gastrointestinal tract, which includes the esophagus, stomach, and duodenum. Pain during a bowel movement would suggest an issue in the lower gastrointestinal tract, which is typically examined with a colonoscopy. Choices A, C, and D are not probable reasons for an endoscopy procedure as they relate to symptoms in the upper gastrointestinal tract or are not specific to gastrointestinal issues. Aspiration noted on a honey-thick diet could indicate a risk of aspiration pneumonia related to swallowing difficulties, which can be assessed through an endoscopy. Pain felt in the left upper quadrant may be related to conditions like gastritis or peptic ulcers that can be investigated using an endoscopy. Right shoulder pain can be a referred pain from conditions like gallbladder disease that can also be evaluated with an endoscopy.