Nokea
A client with a history of chronic lymphocytic leukemia is admitted with fatigue. The nurse should monitor the client for which of the following?
- A. Anemia.
- B. Hyperkalemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Chronic lymphocytic leukemia can cause anemia due to bone marrow suppression, leading to fatigue.
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A client being treated for a comminuted fractured tibia asks the nurse to explain what a comminuted fracture means. The nurse should give which response?
- A. It means the fracture is incomplete.
- B. It means the bone is partially fractured.
- C. It means the bone fractured with splintering of the bone into fragments.
- D. It means the skin or mucous membrane was broken when the fracture occurred.
Correct Answer: C
Rationale: A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone. One side of the bone is fractured, and the other side is bent. A compound fracture, also called an open fracture, is one in which the skin or mucous membrane has been broken, and the wound extends to the depth of the fractured bone.
The nurse is instructing a Hindu client to increase protein in the diet. Which of the following foods are appropriate to include in this client's diet? Select all that apply.
- A. Lentil soup.
- B. Hamburger.
- C. 3 mm.
- D. Veal cutlet.
- E. Broiled fish sandwich.
Correct Answer: A
Rationale: Hindus typically follow a vegetarian diet, so lentil soup is appropriate, while meat-based options like hamburger, veal, and fish are not.
A client with a history of epilepsy is admitted with status epilepticus. The nurse should prioritize which of the following interventions?
- A. Administer lorazepam intravenously.
- B. Apply oxygen via nasal cannula.
- C. Insert a nasogastric tube.
- D. Position the client supine.
Correct Answer: A
Rationale: Lorazepam is the priority to stop seizures in status epilepticus.
Select the nurse case management model used for patient care delivery that is accurately paired with one of its descriptors:
- A. The ProACT Model: Registered nurses perform the role of the primary nurse in addition to the related coding and billing functions
- B. The Collaborative Practice Model: The registered nurse performs the role of the primary nurse in addition to the role of the clinical case manager with administrative, supervisory and fiscal responsibilities
- C. The Case Manager Model: The management and coordination of care for clients throughout a facility who share the same DRG or medical diagnosis
- D. The Triad Model of Case Management: The joint collaboration of the social worker, the nursing case manager, and the utilization review team
Correct Answer: D
Rationale: The Triad Model of Case Management accurately describes the collaboration among the social worker, nursing case manager, and utilization review team to coordinate care and optimize outcomes.
The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply.
- A. Ask the client to rub lotion over the hands every day after bathing.
- B. Encourage physical activity, such as ambulation.
- C. Provide frequent contacts for communication and socialization.
- D. Provide family education.
- E. Encourage involvement of family and friends.
Correct Answer: A,B,C,E
Rationale: Non-restrictive interventions like applying lotion, encouraging physical activity, providing social interaction, and involving family can address the behavior's underlying causes, such as anxiety or sensory needs, while promoting client autonomy and engagement.