Nokea
A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?
- A. Lethargy
- B. Agitation
- C. Ataxia
- D. Hearing loss
Correct Answer: A
Rationale: Lethargy is a critical finding that requires the nurse's immediate attention when a client with a recent skull fracture is readmitted to the hospital. It can indicate increased intracranial pressure or other serious complications such as hemorrhage or infection. Addressing lethargy promptly is crucial to prevent further deterioration. Agitation, ataxia, and hearing loss are important to assess but do not signify the same level of urgency as lethargy in this context.
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Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?
- A. Sports and games with rules
- B. Finger paints and water play
- C. "Dress-up" clothes and props
- D. Chess and television programs
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A male client is brought to the emergency department as the result of a motorcycle accident. He was not wearing a helmet at the time of the accident and states that he has no intention of ever wearing one. Within the framework of the Transtheoretical Model (TTM), which response should the nurse provide?
- A. Wearing a helmet or not is certainly an individual decision.
- B. You should seriously consider wearing a helmet.
- C. Riding a motorcycle with a helmet increases your safety.
- D. I really think you don't have the facts about helmet use.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
- A. Expiratory wheezes
- B. Blurred vision
- C. Ascites
- D. Dilated pupils
Correct Answer: C
Rationale: Ascites is a common finding in clients with portal hypertension. Portal hypertension results in increased pressure in the portal vein, leading to the development of ascites, which is the accumulation of fluid in the abdominal cavity. Expiratory wheezes (Choice A) are associated with respiratory conditions. Blurred vision (Choice B) is more commonly linked to eye disorders or neurological issues. Dilated pupils (Choice D) can be related to neurological conditions or drug effects, but not specifically to portal hypertension.
A client with heart failure is receiving digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of digoxin toxicity?
- A. Tachycardia
- B. Hypotension
- C. Bradycardia
- D. Hyperglycemia
Correct Answer: C
Rationale: The correct answer is C: Bradycardia. Digoxin toxicity often presents with bradycardia, which is a common sign of toxicity associated with this medication. Tachycardia (Choice A) is not typically seen with digoxin toxicity. Hypotension (Choice B) can occur but is less specific to digoxin toxicity. Hyperglycemia (Choice D) is not a typical sign of digoxin toxicity. Therefore, monitoring for bradycardia is crucial in clients receiving digoxin to detect toxicity early.
When planning the care for a young adult client diagnosed with anorexia nervosa, which of these concerns should the nurse determine to be the priority for long term mobility?
- A. Digestive problems
- B. Amenorrhea
- C. Electrolyte imbalance
- D. Blood disorders
Correct Answer: B
Rationale: The correct answer is B: Amenorrhea. Amenorrhea, or the absence of menstruation, is a common long-term consequence of anorexia nervosa due to low body weight and hormonal imbalances. Addressing amenorrhea is crucial for the patient's overall health and reproductive potential.
Choice A, Digestive problems, may also be a concern in anorexia nervosa, but in terms of long-term mobility, amenorrhea takes priority because of its impact on hormonal balance and bone health.
Choice C, Electrolyte imbalance, is important to address in anorexia nervosa due to potential cardiac complications, but it is not directly linked to long-term mobility concerns.
Choice D, Blood disorders, while they can occur in anorexia nervosa, are not as directly related to long-term mobility as amenorrhea, which can significantly affect bone health and mobility in the future.