Nokea
A client post-amputation is experiencing depression. Which nursing action is most appropriate?
- A. Administer an antidepressant immediately.
- B. Encourage participation in a support group.
- C. Limit discussions about the amputation.
- D. Schedule a physical therapy session.
Correct Answer: B
Rationale: Encouraging participation in a support group fosters emotional coping and peer support.
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A hospice client's family asks how they will know when death is imminent. The nurse should explain that signs include:
- A. Increased energy and mobility.
- B. Cheyne-Stokes respirations.
- C. Improved blood pressure.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Cheyne-Stokes respirations, characterized by alternating periods of apnea and deep breathing, are a common sign of imminent death.
A 57-year-old with diabetes insipidus is hospitalized for care. Which finding should the nurse report to the physician?
- A. Urine output of 350 mL in 8 hours.
- B. Urine specific gravity of 1.001.
- C. Potassium of 4.0 mEq.
- D. Weight gain.
Correct Answer: B
Rationale: Diabetes insipidus causes excessive dilute urine output. A urine specific gravity of 1.001 (very dilute) indicates worsening of the condition and should be reported. The other findings are within normal or expected ranges.
A client complaining of numbness from the back of his left buttock to the dorsum of his foot and big toe is scheduled to undergo a laminectomy. The operative consent form states, 'a left lumbar laminectomy of L3-4.' Which of the following should the nurse do next?
- A. Have the client sign the consent form.
- B. Call the surgeon.
- C. Change the consent form.
- D. Review the client's history.
Correct Answer: B
Rationale: The consent form must match the client's symptoms, which suggest L5-S1 involvement, not L3-4. The surgeon must clarify.
When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?
- A. Aching pain in the left calf
- B. Burning pain in the left calf
- C. Numbness and tingling in the left leg
- D. Coldness of the left foot and ankle
Correct Answer: D
Rationale: Complete arterial obstruction causes severe ischemia, leading to coldness of the affected limb (foot and ankle) due to absent blood flow. Aching or burning pain and numbness/tingling suggest partial occlusion or neuropathy, not complete obstruction.
The nurse is caring for a client in the emergency department who has overdosed on morphine. Which medication does the nurse anticipate to be ordered to reverse the effects of morphine?
- A. sodium bicarbonate
- B. flumazenil
- C. diphenhydramine
- D. naloxone
Correct Answer: D
Rationale: Naloxone is an opioid antagonist used to reverse morphine overdose effects, such as respiratory depression.