Nokea
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
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The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following should the nurse assess next?
- A. Bladder distention.
- B. Headache.
- C. Postoperative pain.
- D. Ability to move the legs.
Correct Answer: A
Rationale: Epidural anesthesia can cause urinary retention due to sensory and motor nerve blockade. Assessing for bladder distention is critical to prevent complications like bladder overdistension.
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.
The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment findings should lead the nurse to suspect possible nerve damage?
- A. Numbness.
- B. Bleeding.
- C. Dislocation.
- D. Pinkness.
Correct Answer: A
Rationale: Numbness indicates potential nerve damage, requiring urgent evaluation.
The nurse is preparing to administer ten units of regular insulin and twenty units of NPH insulin. Which of the following actions is correct when mixing the insulins?
- A. Aspirate insulin from the NPH vial first.
- B. Roll the regular insulin vial prior to aspirating insulin.
- C. Aspirate the regular insulin first before NPH.
- D. Instill air into the regular insulin vial first.
Correct Answer: C
Rationale: Regular insulin is drawn up first to prevent contamination of the clear insulin with the cloudy NPH.
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.