Nokea
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:
- A. Showing the location of the obstruction and the collateral circulation
- B. Scanning the affected extremity and identifying the areas of volume changes
- C. Using ultrasound to estimate the velocity change in the blood vessels
- D. Determining how long the client can walk
Correct Answer: A
Rationale: An arteriogram involves injecting contrast dye to visualize arteries, revealing the location of obstructions and collateral circulation in occlusive arterial disease. It is a direct imaging method, unlike ultrasound (velocity changes) or volume scans, and walking duration is not assessed.
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What is the priority nursing action for a client with a suspected neurological deficit?
- A. Perform a full neurological assessment.
- B. Administer pain medication.
- C. Monitor vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Monitoring vital signs is the priority to ensure stability and detect acute changes in a client with a suspected neurological deficit.
A client has vertigo. Which of the following actions would be most appropriate for the nursing diagnosis of Risk for injury related to altered immobility and gait disturbances? Select all that apply.
- A. The client assumes safe position when dizzy.
- B. The client experiences no falls.
- C. The client performs vestibular/balance exercises.
- D. The client demonstrates family involvement.
- E. The client keeps head still when dizzy.
Correct Answer: A,B,C,E
Rationale: Appropriate actions include assuming a safe position (e.g., sitting or lying down), preventing falls, performing vestibular exercises to improve balance, and keeping the head still during vertigo to minimize symptoms and reduce injury risk.
Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops?
- A. Inserting a nasogastric (NG) tube.
- B. Restricting fluids to 1,000 mL/day.
- C. Administering I.V. salt-poor albumin.
- D. Implementing a low-protein diet.
Correct Answer: D
Rationale: A low-protein diet (D) reduces ammonia production in hepatic encephalopathy. NG tubes (A), fluid restriction (B), and albumin (C) are not primary interventions.
The most appropriate suggestion for the hospice nurse to give a woman whose husband died 3 months ago and her three young children would be to:
- A. Seek group counseling support for the three children.
- B. Request individual counseling and medication to manage depression.
- C. Remind her gently that bereavement care before the child's effective grieving.
- D. Continue her bereavement support through hospice.
Correct Answer: D
Rationale: Continuing bereavement support through hospice provides ongoing emotional support for the woman and her children, tailored to their needs during grief.
A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Maintain the head of the bed at 30 to 40 degrees.
- B. Teach the client how to use esophageal speech.
- C. Initiate small feedings of soft goods.
- D. Irrigate drainage tubes as needed.
Correct Answer: A
Rationale: Elevating the head of the bed 30–40 degrees reduces swelling and maintains airway patency post-laryngectomy. Esophageal speech training is premature immediately post-surgery. Feedings are typically delayed until swallowing is safe. Drainage tubes are not routinely irrigated.