Nokea
A client wanders away from home and is found 48 hours later sleeping on a park bench. The client is awake, alert, and oriented but cannot recall name, address, or events that occurred in the past 2 days. What is the priority nursing action?
- A. Contact family members
- B. Encourage the client to recall recent events
- C. Measure vital signs
- D. Monitor mental status
Correct Answer: C
Rationale: Measuring vital signs is the priority to ensure physiological stability in a client with amnesia, which may indicate a medical emergency like transient global amnesia.
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A 19-year-old primigravida is admitted for observation due to a sudden increase in blood pressure. The doctor suspects a diagnosis of pregnancy-induced hypertension. Which of the following is considered a significant factor in the development of pregnancy-induced hypertension?
- A. Maternal age
- B. Nutritional status of mother
- C. Pre-pregnant weight
- D. History of hypertension
Correct Answer: D
Rationale: A history of hypertension is a significant risk factor for developing pregnancy-induced hypertension (preeclampsia), as it indicates a predisposition to vascular issues.
The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of
- A. Anonymity
- B. Beneficence
- C. Justice
- D. Autonomy
Correct Answer: D
Rationale: Autonomy. Individuals must be free to make independent decisions about participation in research without coercion from others.
The nurse is reinforcing teaching for the parents of a child newly diagnosed with hemophilia. Which long-term complication is important for the nurse to discuss?
- A. Heart valve injury
- B. Intellectual disability
- C. Joint destruction
- D. Recurrent pneumonia
Correct Answer: C
Rationale: Hemophilia causes recurrent joint bleeds, leading to joint destruction (hemophilic arthropathy), a key long-term complication.
A client with a diagnosis of acoustic neuroma asks the nurse to explain what is wrong with his hearing. The nurse's response is based on the knowledge that an acoustic neuroma is:
- A. A malignant tumor of the inner ear with rapid metastasis
- B. A malignant tumor of the fifth cranial nerve that affects hearing and chewing
- C. A benign tumor of the auditory nerve that may cause destruction to the cerebellum
- D. A highly vascular benign lesion of the middle ear that arises from the jugular vein
Correct Answer: C
Rationale: An acoustic neuroma is a benign tumor of the eighth cranial (auditory) nerve that can affect hearing and balance and may cause compression of nearby structures, such as the cerebellum. Answer A is incorrect because acoustic neuromas are benign, not malignant. Answer B is incorrect because it involves the fifth cranial nerve, which is unrelated. Answer D refers to a glomus tumor, not an acoustic neuroma.
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
- A. Decreased breath sounds in right lower lobe
- B. Aspiration of a residual of 100 cc of formula
- C. Decrease in bowel sounds
- D. Urine output of 250 cc in past 8 hours
Correct Answer: A
Rationale: Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees of head elevation during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if the client is receiving continuous feeding.