Nokea
A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance?
- A. What daily activities were you able to do 6 months ago compared with the present?'
- B. How long have you had this problem?'
- C. Have you been able to keep up with all your usual activities?'
- D. Are you more tired now than you used to be?'
Correct Answer: A
Rationale: To assess activity intolerance, the nurse should compare the client's current activity level with their previous capabilities. Asking about specific activities performed 6 months ago versus now provides concrete data on the extent of intolerance. The other questions are less specific and do not directly quantify changes in activity capacity.
You may also like to solve these questions
Which of the following statements should the nurse include in the teaching session when preparing a client for arthrocentesis? Select all that apply.
- A. A local anesthetic agent may be injected into the joint site for your comfort.'
- B. A syringe and needle will be used to withdraw fluid from your joint.'
- C. The procedure, although not painful, will provide immediate relief.'
- D. We'll want you to keep your joint active after the procedure to increase blood flow.'
- E. You will need to wear a compression bandage for several days after the procedure.'
Correct Answer: A,B
Rationale: Arthrocentesis involves using a needle and syringe to withdraw fluid, often with a local anesthetic for comfort. The procedure may be painful, and rest, not activity, is typically recommended post-procedure. A compression bandage is not standard.
A client with acute renal failure has a low calcium level. The nurse should monitor for:
- A. Tetany.
- B. Hypertension.
- C. Bradycardia.
- D. Edema.
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
The nurse should assess clients with chronic open-angle glaucoma (COAG) for:
- A. Eye pain.
- B. Excessive lacrimation.
- C. Colored light flashes.
- D. Decreasing peripheral vision.
Correct Answer: D
Rationale: Chronic open-angle glaucoma typically presents with a gradual loss of peripheral vision due to optic nerve damage from increased intraocular pressure.
A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing an exacerbation of ulcerative colitis?
- A. A demanding job.
- B. Recent travel.
- C. A high-fiber diet.
- D. Stopping corticosteroid therapy.
Correct Answer: D
Rationale: Stopping corticosteroid therapy can lead to an exacerbation of ulcerative colitis, as corticosteroids help control inflammation. A demanding job or recent travel may contribute to stress but are less directly linked. A high-fiber diet is generally beneficial for managing symptoms unless during an acute flare. CN: Physiological adaptation; CL: Analyze
A client with a fractured right femur has not had any immunizations since childhood. Which of the following biological products should the nurse administer to provide the client with passive immunity for tetanus?
- A. Tetanus toxoid.
- B. Tetanus antigen.
- C. Tetanus vaccine.
- D. Tetanus antitoxin.
Correct Answer: D
Rationale: Tetanus antitoxin provides passive immunity, neutralizing existing toxin in unvaccinated clients.