Nokea
A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which sign or symptom?
- A. Increased pulse.
- B. Nausea.
- C. Tarry stools.
- D. Abdominal cramps.
Correct Answer: C
Rationale: Tarry stools are a hallmark sign of a slow gastrointestinal bleed due to digested blood.
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You will be providing nursing care prior to, during and after electroconvulsive therapy for your client who is severely depressed. Which of the following is an appropriate nursing intervention for this client?
- A. Maintain the client with NPO status for at least 4 hours prior to this procedure.
- B. Teach the client about the fact that they may experience muscle flaccidity.
- C. Teach the client about the fact that they may have a headache after the ECT.
- D. Maintain the client on continuous hemodynamic monitoring after the ECT.
Correct Answer: C
Rationale: Headache is a common side effect of ECT, and educating the client about this prepares them for post-procedure expectations.
A nulligravid client with gestational diabetes tells the nurse that she had a reactive nonstress test 3 days ago and asks, 'What does that mean?' The nurse explains that a reactive nonstress test indicates which of the following about the fetus?
- A. Evidence of some compromise that will require delivery soon.
- B. Fetal well-being at this point in the pregnancy.
- C. Evidence of late decelerations occurring during the test.
- D. No accelerations demonstrated within a 20-minute period.
Correct Answer: B
Rationale: A reactive nonstress test, showing fetal heart rate accelerations, indicates fetal well-being.
The nurse is caring for a client with a history of diverticulitis. Which of the following foods should the nurse recommend during the acute phase?
- A. Clear liquids.
- B. High-fiber foods.
- C. Red meat.
- D. Whole grains.
Correct Answer: A
Rationale: Clear liquids reduce bowel irritation during acute diverticulitis.
The nurse is monitoring a client with a fracture to the left arm. Which sign observed by the nurse is consistent with impaired venous return in the area?
- A. Increasing edema
- B. Weakened distal pulse
- C. Pallor or blotchy cyanosis
- D. Continued pain despite medication
Correct Answer: A
Rationale: Impaired venous return is characterized by increasing edema. In the client with a fracture, this is most often prevented by elevating the limb. The other options identify signs of arterial damage, which can occur if the artery is contused, thrombosed, lacerated, or becomes spastic.
A client is being treated for acute low back pain. Which of these clinical manifestations must be reported to the physician immediately?
- A. Diffuse, aching sensation in the L4 to L5 area
- B. New onset of footdrop
- C. Pain in the lower back when the leg is lifted
- D. Pain in the lower back that radiates to the hip
Correct Answer: B
Rationale: New onset footdrop indicates possible nerve compression or damage, requiring immediate reporting to prevent permanent impairment. Other symptoms are common in low back pain and less urgent.