Nokea
A client with a history of osteoarthritis is admitted with complaints of joint stiffness. The nurse should expect the client to have:
- A. Pain with activity
- B. Morning stiffness lasting hours
- C. Symmetrical joint involvement
- D. Systemic symptoms like fever
Correct Answer: A
Rationale: Osteoarthritis causes joint pain worsened by activity due to cartilage degeneration, unlike rheumatoid arthritis, which involves prolonged morning stiffness.
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A client with a history of stroke is admitted with complaints of hemiparesis. The nurse should give priority to:
- A. Providing physical therapy
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering anticoagulants
Correct Answer: A
Rationale: Physical therapy improves strength and mobility in hemiparesis post-stroke, promoting recovery.
The priority nursing goal when working with an autistic child is:
- A. To establish trust with the child
- B. To maintain communication with the family
- C. To promote involvement in school activities
- D. To maintain nutritional requirements
Correct Answer: A
Rationale: The priority nursing goal when working with an autistic child is establishing a trusting relationship. Maintaining a relationship with the family is important but having the trust of the child is a priority. To promote involvement in school activities is inappropriate for a child who is autistic. Maintaining nutritional requirements is not the primary problem of the autistic child.
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to:
- A. Check FHT
- B. Notify the attending physician
- C. Turn off the IV oxytocin
- D. Prepare for the delivery because the client is probably in transition
Correct Answer: C
Rationale: FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. The physician should be notified, but this is not the first intervention the nurse should do. The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, 'Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.' At this time the nurse's greatest concern is that:
- A. The client may contract an infection as a result of being exposed to large crowds at spring break
- B. The client does not grasp the full impact of her illness
- C. The client may require transfusion before leaving for spring break
- D. The causative agent be identified and treatment begun
Correct Answer: B
Rationale: The client could contract an infection, but at this point it is not the most pertinent issue. The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. A bone marrow is done first to make a definitive diagnosis; then treatment may begin.
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi, wheezing) indicate mucus obstruction, signaling the need for suctioning. Oxygen saturation, respiratory rate, and ABGs are less specific.