Nokea
A client with a history of a stroke is being taught to use a quad 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
Correct Answer: C
Rationale: The quad cane should be used on the weak side to support the affected leg post-stroke, improving balance. Holding in the strong hand or advancing with the strong leg is incorrect.
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The nurse is in the hallway and one of the visitors faints. The nurse should:
- A. Sit the victim up and lightly slap his face
- B. Elevate the victim's legs
- C. Apply a cool cloth to the victim's neck and forehead until he recovers
- D. Sit the victim up and place the head between the knees
Correct Answer: B
Rationale: Sitting the client up defeats the goal of re-establishing cerebral blood flow. Elevating the legs anatomically redirects blood flow to the cerebral area. This strategy is a nice general comfort measure after the victim has regained consciousness. This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.
The nurse is assessing a client with suspected diabetic ketoacidosis. Which finding is most expected?
- A. Kussmaul respirations
- B. Hypertension
- C. Bradycardia
- D. Clear breath sounds
Correct Answer: A
Rationale: Kussmaul respirations (rapid, deep breathing) are a compensatory mechanism in diabetic ketoacidosis to eliminate excess carbon dioxide and correct acidosis. Hypotension, tachycardia, and clear breath sounds are more common.
The nurse is caring for a client with a suspected stroke. Which assessment finding is most concerning?
- A. Mild headache
- B. Unilateral facial droop
- C. Slight dizziness
- D. Fatigue
Correct Answer: B
Rationale: Unilateral facial droop is a classic sign of stroke, indicating neurological deficit and requiring urgent evaluation. Headache (A), dizziness (C), and fatigue (D) are less specific.
Why is Phytonadione (vitamin K) administered to a newborn shortly after birth?
- A. To stop hemorrhage
- B. To treat infection
- C. To replace electrolytes
- D. To facilitate clotting
Correct Answer: D
Rationale: Newborns have low vitamin K levels, necessary for clotting factor synthesis. Phytonadione is given to facilitate clotting and prevent hemorrhagic disease of the newborn. It does not stop active hemorrhage, treat infections, or replace electrolytes.
The client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor for which potential side effect?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypoglycemia
- D. Hypertension
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia by reducing potassium excretion. Hypokalemia is caused by other diuretics, hypoglycemia is unrelated, and spironolactone lowers blood pressure.