Nokea
A client with disseminated intravascular coagulation develops ventricular microvascular thrombosis. The nurse should assess the client for:
- A. Hemoptysis.
- B. Focal ischemia.
- C. Petechiae.
- D. Hematuria.
Correct Answer: B
Rationale: Microvascular thrombosis in DIC can cause focal ischemia by obstructing small vessels, leading to tissue damage in organs like the kidneys or brain. Hemoptysis, petechiae, and hematuria are related to bleeding, not thrombosis.
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A client has a chest tube attached to a waterseal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine:
- A. The lung has fully expanded.
- B. The lung has collapsed.
- C. The chest tube is in the pleural space.
- D. The mediastinal space has decreased.
Correct Answer: A
Rationale: Lack of fluctuation in the water-seal column suggests the lung has fully expanded, resolving the pneumothorax. Collapsed lung, tube placement, or mediastinal changes would show other signs.
A 90-year-old male complains of feeling cold in his room even though the thermostat is set at 75°F (24°C). The client probably feels cold because older adults have:
- A. Increased cellular cohesion.
- B. Increased moisture content of the stratum corneum.
- C. Slower cellular renewal time.
- D. Decreased ability to thermoregulate.
Correct Answer: D
Rationale: Older adults have reduced thermoregulation due to decreased subcutaneous fat, vascular changes, and slower metabolic rate, making them feel colder.
A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse knows that the client has understood the nurse's instructions when he states he will:
- A. Avoid exercise
- B. Lose weight
- C. Perform leg lifts every 4 hours
- D. Wear support hose, using rubber bands to hold the stockings up
Correct Answer: B
Rationale: Weight loss reduces pressure on veins and improves circulation, critical for managing DVT and thrombophlebitis in an obese client. Avoiding exercise increases stasis, leg lifts are insufficient alone, and rubber bands can cause constriction, negating support hose benefits.
The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation?
- A. Use of alcohol.
- B. Frequent use of mouthwash.
- C. Lack of vitamin B12.
- D. Lack of regular teeth cleaning by a dentist.
Correct Answer: A
Rationale: Alcohol use is a well-established primary risk factor for oral cancer, often acting synergistically with tobacco use. Frequent mouthwash use, vitamin B12 deficiency, and lack of dental cleanings are not primary risk factors for oral cancer.
The nurse is teaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which of the following?
- A. How much does your family need to be involved in learning about your condition?'
- B. What is required for your family to manage your symptoms?'
- C. What activities are most important for you to be able to maintain control of your diabetes?'
- D. What do you know about your medications and condition?'
Correct Answer: D
Rationale: An empowerment approach focuses on the client's knowledge and needs. Starting with what the client already knows about their condition and medications helps tailor education effectively.