Nokea
A client with a history of a stroke is being taught to use a cane. The nurse should teach the client to:
- A. Hold the cane in the strong hand
- B. Advance the cane with the strong leg
- C. Use the cane on the weak side
- D. Lean heavily on the cane while walking
Correct Answer: C
Rationale: The cane should be used on the weak side to support the affected leg, improving balance and gait post-stroke. Holding it in the strong hand or advancing with the strong leg is incorrect.
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Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
- A. A fetal heart rate of 120-130 bpm
- B. A baseline variability of 6-10bpm
- C. Accelerations in FHR with fetal movement
- D. A recurrent rate of 90-100 bpm at the end of the contractions
Correct Answer: D
Rationale: A recurrent fetal heart rate of 90-100 bpm at the end of contractions (late decelerations) is ominous indicating fetal hypoxia from uteroplacental insufficiency. Normal heart rate (120-130) variability and accelerations are reassuring findings.
The nurse is teaching a client with hypertension about dietary modifications. Which food choice indicates a need for further teaching?
- A. Fresh apple
- B. Baked chicken
- C. Canned soup
- D. Steamed broccoli
Correct Answer: C
Rationale: Canned soup is high in sodium, which exacerbates hypertension, indicating a need for further teaching. Apple (A), chicken (B), and broccoli (D) are low-sodium and appropriate.
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
- A. A tension pneumothorax
- B. An asthma attack
- C. Pneumonia
- D. Pulmonary embolus
Correct Answer: B
Rationale: A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
- A. Keep breathing with your abdominal muscles as long as you can.
- B. Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16-20 times a minute with shallow chest breaths.
- C. Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.
- D. If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.
Correct Answer: B
Rationale: Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. It is important to assume a comfortable position in labor, but the Lamaze-prepared laboring woman is taught to breathe with her chest, not abdominal, muscles. When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-9 breaths/min.
A client's wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson's disease, and she is telling his nurse that he has been doing 'strange things.' The nurse reassures the wife that the following behavior is normal with Parkinson's disease:
- A. Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods.'
- B. Your husband may move his hands in motions that look like he is rolling a pill between his fingers.'
- C. Twitching of the muscles is to be expected and can occur at any time during the day.'
- D. Parkinson's disease causes severe pain in the joints. You should give your husband Tylenol at those times.'
Correct Answer: B
Rationale: Clients with Parkinson's disease generally experience stiffness and rigid movement. Pill-rolling movements are a symptom experienced by the Parkinson client. Twitching of the muscles is not an expected symptom of Parkinson's disease. Parkinson's disease does not cause joint pain. Mild muscular pain may be present.