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A client who is about to undergo hip arthroplasty tells the nurse she is afraid of not receiving adequate anesthesia during the procedure. Which of the following is an appropriate response?
- A. I will call the anesthesiologist right away.
- B. Can you tell me more about this concern?
- C. You have nothing to be concerned about. You have a competent anesthesiologist.
- D. I had a similar procedure and definitely received enough anesthesia.
Correct Answer: B
Rationale: Asking the client to elaborate allows for exploration of their concerns and reassurance through proper information.
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A nurse is collecting data from a client who reports persistent vomiting, dizziness, palpitations, and numbness and tingling in his fingers and toes and around his mouth. The nurse notes the client's respirations are slow and shallow. The nurse should suspect that the client has developed which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: B
Rationale: The correct answer is B: Metabolic alkalosis. The client's symptoms of vomiting, dizziness, palpitations, numbness and tingling, along with slow and shallow respirations, indicate a loss of hydrogen ions (H⁺) and chloride ions (Cl⁻) due to prolonged vomiting, leading to metabolic alkalosis. Vomiting causes a loss of stomach acid (HCl), leading to an increase in blood pH. Respiratory acidosis (C) results from inadequate ventilation, causing CO₂ retention and increased carbonic acid in the blood. Respiratory alkalosis (D) is characterized by hyperventilation and decreased CO₂ levels. Metabolic acidosis (A) involves a decrease in blood pH due to an excess of metabolic acids or a loss of bicarbonate ions.
A nurse is reinforcing teaching with a client about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development?
- A. Generativity versus stagnation
- B. Identity versus role diffusion
- C. Intimacy versus isolation
- D. Trust versus mistrust
Correct Answer: C
Rationale: The correct answer is C: Intimacy versus isolation. According to Erikson's psychosocial theory, the stage of intimacy versus isolation occurs in young adulthood. This stage focuses on forming close relationships and commitments with others. This is a critical time for individuals to develop intimate relationships and establish long-term commitments. Choosing option C is correct as it aligns with the primary task of this stage.
A: Generativity versus stagnation occurs in middle adulthood and focuses on contributing to society.
B: Identity versus role diffusion happens in adolescence and centers on forming a sense of self.
D: Trust versus mistrust is in infancy and relates to developing trust in others.
Thus, option C is the most appropriate choice for the stage involving establishing relationships with commitment.
A nurse is collecting data for a client who has malnutrition resulting from a chronic illness. Which of the following manifestations should the nurse expect to find?
- A. Non-palpable spleen
- B. Slightly moist skin
- C. Presence of surface papillae on tongue
- D. Depigmented hair
Correct Answer: D
Rationale: The correct answer is D: Depigmented hair. Malnutrition can lead to changes in hair color and texture, resulting in depigmented or thinning hair. This is due to the body lacking essential nutrients needed for healthy hair growth. Non-palpable spleen (A) is not typically associated with malnutrition. Slightly moist skin (B) is more likely to be seen in a well-nourished individual. Presence of surface papillae on the tongue (C) is not a common manifestation of malnutrition. Therefore, depigmented hair (D) is the most likely manifestation of malnutrition in this scenario.
A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?
- A. Move body parts rapidly through the movements.
- B. Support extremities above and below joints.
- C. Stretch the body part just beyond the existing range of motion.
- D. Continue moving body parts if muscle spasticity occurs.
Correct Answer: B
Rationale: The correct answer is B: Support extremities above and below joints. This is because supporting the extremities above and below the joints helps to maintain proper alignment and stability during passive range of motion exercises, preventing injury and ensuring effective movement. Moving body parts rapidly (choice A) can cause muscle strain or injury. Stretching the body part beyond existing range (choice C) can lead to muscle or ligament damage. Continuing movement if spasticity occurs (choice D) can exacerbate muscle tightness. This is why choice B is the most appropriate action to take during passive range of motion exercises.
A nurse at a community health clinic is assisting with creating a brochure about testicular cancer. Which of the following information should the nurse include?
- A. Perform a testicular self-examination twice per year.
- B. Palpate the epididymis.
- C. Gently roll the testicles to feel for abnormalities.
- D. Use one hand to palpate the testicles.
Correct Answer: C
Rationale: The correct answer is C: Gently roll the testicles to feel for abnormalities. This is the correct information to include in the brochure because it accurately describes the recommended technique for performing a testicular self-examination. By gently rolling the testicles between the thumb and fingers, individuals can effectively detect any abnormalities such as lumps or swelling, which could be early signs of testicular cancer.
Choice A is incorrect because the recommended frequency for testicular self-examination is once a month, not twice per year. Choice B is incorrect as palpating the epididymis is not the main focus of a testicular self-exam. Choice D is incorrect because using both hands is recommended for better examination.