Nokea
A client with Buerger's disease smokes two packs of cigarettes a day. Smoking cessation is critical or the client may lose the affected extremity. When helping a client change behavior, it is important to know the client's:
- A. Ability to attend support groups
- B. Goals of the treatment
- C. Perception of the negative behavior
- D. Motivation
Correct Answer: D
Rationale: Motivation is critical for behavior change, such as smoking cessation in Buerger's disease, as it drives the client's commitment to quit. Understanding motivation (e.g., desire to avoid amputation) guides tailored interventions. Support groups, treatment goals, and perception are secondary to motivation.
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What is the nurse's best response to a client with Parkinson's experiencing dyskinesia?
- A. Increase medication dose.
- B. Teach relaxation techniques.
- C. Restrict all activity.
- D. Ignore the symptoms.
Correct Answer: B
Rationale: Teaching relaxation techniques can help manage dyskinesia, a side effect of Parkinson's medications.
A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should:
- A. Position the client on a firm mattress
- B. Keep the involved extremity warm with blankets
- C. Position the left leg at or below the body's horizontal plane
- D. Encourage the client to raise and lower his leg four times every hour
Correct Answer: C
Rationale: Positioning the left leg at or below the body's horizontal plane promotes arterial blood flow to the extremity in arteriosclerosis, avoiding gravitational resistance. A firm mattress is irrelevant, warmth is beneficial but secondary, and leg raises may not be feasible pre-revascularization.
Which of the following skin preparations would be best to apply around the client's colostomy?
- A. Karaya.
- B. Petroleum jelly.
- C. Antiseptic cream.
- D. None of the above
Correct Answer: A
Rationale: Karaya is a natural skin barrier that protects the skin around the stoma from irritation and is commonly used in ostomy care. Petroleum jelly is not suitable as it can interfere with adhesion of the ostomy appliance, and antiseptic cream is not typically used for routine skin protection around a stoma. CN: Physiological adaptation; CL: Apply
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (A) is essential to identify etiology. Interference with tests (B), general alcoholism screening (C), or disregarding beliefs (D) are not accurate explanations.
A client with aortic stenosis complains of increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis.
- A. 1
- B. 2
- C. 3
- D. 4
- E. 5
Correct Answer: A
Rationale: The stethoscope is placed at the second intercostal space right of sternum (1) to assess the aortic area. (2) is the pulmonic valve area, (3) is Erb’s point, (4) is the Tricuspid valve area, and (5) is the Mitral valve area.