Nokea
A client with a history of a tonsillectomy is being discharged. The nurse should teach the client to:
- A. Gargle with warm salt water
- B. Avoid cold liquids
- C. Report excessive swallowing
- D. Use a straw for fluids
Correct Answer: C
Rationale: Excessive swallowing post-tonsillectomy may indicate bleeding, a serious complication requiring immediate reporting. Gargling, cold liquids, and straws may irritate the surgical site.
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The nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding is most indicative?
- A. Bilateral leg edema
- B. Warm, red, swollen calf
- C. Mild leg cramping
- D. Pale, cool foot
Correct Answer: B
Rationale: A warm, red, swollen calf is a classic sign of DVT due to clot-related inflammation. Bilateral edema (A) suggests heart failure, cramping (C) is nonspecific, and pale/cool foot (D) indicates arterial occlusion.
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
- A. Crackles or rales on the affected side
- B. Bradypnea and bradycardia
- C. Shortness of breath and sharp pain on the affected side
- D. Increased breath sounds on the affected side
Correct Answer: C
Rationale: With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).
A client with Parkinson's disease is scheduled for stereotactic surgery. Which finding indicates that the surgery had its intended effect?
- A. The client no longer has intractable tremors.
- B. The client has sufficient production of dopamine.
- C. The client no longer requires any medication.
- D. The client will have increased production of serotonin.
Correct Answer: A
Rationale: Stereotactic surgery, such as deep brain stimulation, aims to reduce symptoms like intractable tremors in Parkinson's disease. It does not directly increase dopamine or serotonin production, nor does it eliminate the need for medication entirely.
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
- A. Anxiety
- B. Impaired skin integrity
- C. Fluid volume deficit
- D. Nutrition altered, less than body requirements
Correct Answer: C
Rationale: Ulcerative colitis causes diarrhea, leading to significant fluid and electrolyte loss, making fluid volume deficit a priority nursing diagnosis to prevent dehydration and shock. Anxiety, skin integrity, and nutrition are secondary concerns.
In an interview for suspected child abuse, the child's mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child's father states, 'Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child.' Based on this remark, the nurse would make the following nursing diagnosis:
- A. Fear related to retaliation by the father
- B. Actual injury related to poor impulse control by the father
- C. Ineffective coping
- D. Altered family process related to physical abuse
Correct Answer: D
Rationale: There is no evidence of fear as the child is unable to communicate. There is actual injury, but the parents have not yet admitted causing the child's injuries. This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.