Nokea
A client with peripheral neuropathy due to cirrhosis is at risk for injury. What should the nurse do?
- A. Protect the client's feet from injury
- B. Apply a heating pad to the affected area
- C. Keep the client's feet elevated
- D. Assess the feet and legs for jaundice
Correct Answer: A
Rationale: Protecting the client's feet from injury is critical as peripheral neuropathy can lead to decreased sensation and increased risk of trauma. This measure helps prevent wounds, ulcers, and other complications. Applying a heating pad (Choice B) can worsen symptoms and cause burns due to decreased sensation. Keeping the client's feet elevated (Choice C) may help reduce swelling but does not directly address the risk of injury. Assessing for jaundice (Choice D) is important in cirrhosis but is not directly related to the client's risk of injury due to peripheral neuropathy.
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At the end of a 12-hour shift, the PN observes the urine in a client's drainage bag as seen in the picture. Which action should the PN take next?
- A. Offer to administer a prescribed PRN analgesic
- B. Obtain a finger stick capillary glucose level
- C. Determine if the client's bladder feels distended
- D. Note the most recent white blood cell count
Correct Answer: D
Rationale: Noting the white blood cell count is the most appropriate action in this situation. Changes in urine appearance could indicate infection, and assessing the white blood cell count helps in evaluating the possibility of infection. This is crucial for understanding the client's overall condition. The other options are not directly related to assessing infection based on urine appearance. Offering analgesics, checking glucose levels, or determining bladder distention may not address the underlying issue of a potential infection.
How does the home care nurse determine that a 78-year-old client is unable to remain in his current residence alone?
- A. The goals set by the client
- B. The learning level of the client
- C. Assessing the home environment
- D. The distractions in the client's home
Correct Answer: C
Rationale: The correct answer is assessing the home environment. This process is vital in evaluating whether an elderly client can safely live independently. Factors like safety hazards and the client's ability to handle daily activities are considered during this assessment. Choices A, B, and D are incorrect because determining the client's ability to remain in his residence alone relies more on evaluating the home environment for safety and suitability rather than the client's goals, learning level, or distractions in the home.
What should the nurse do to complete a focused assessment for a female client with inflamed and painful hemorrhoids?
- A. Determine if the client uses any over-the-counter preparations for hemorrhoids
- B. Place the client in a standing position, leaning over the exam bed for inspection
- C. Position the client in the left lateral position to inspect the perineal area for fissures or sacs
- D. Ask the client how long she has experienced discomfort related to hemorrhoids
Correct Answer: D
Rationale: Asking the client about the duration of discomfort related to hemorrhoids is the best intervention to implement for a focused assessment. This information provides important context for assessing the severity and chronicity of the condition, which is crucial for developing an appropriate care plan. Choices A, B, and C do not directly address the need to gather information about the duration of symptoms, which is essential for understanding the client's condition.
The PN identifies an electrolyte imbalance, exhibited by changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first?
- A. Record usual eating patterns
- B. Evaluate for muscle cramping
- C. Document abdominal girth
- D. Elevate both legs on pillows
Correct Answer: B
Rationale: Evaluating for muscle cramping, which is a sign of electrolyte imbalance, is crucial in this scenario. Electrolyte imbalances, especially involving potassium or calcium, can lead to serious complications such as arrhythmias or seizures, which need immediate attention. Recording eating patterns (choice A) may be important for overall assessment but is not the priority in this situation. Documenting abdominal girth (choice C) and elevating legs on pillows (choice D) are not directly related to addressing the immediate concern of electrolyte imbalance and its potential complications.
What disorder closely matches Suzy's symptoms?
- A. Antisocial personality disorder
- B. Borderline personality disorder
- C. Schizoid personality disorder
- D. Dissociative Identity Disorder
Correct Answer: B
Rationale: Suzy's symptoms are characteristic of Borderline Personality Disorder (BPD). BPD includes instability in relationships, self-image, and emotions, as well as impulsivity and self-harm. Choice A, Antisocial personality disorder, is characterized by a disregard for others' rights and lack of empathy, which does not align with Suzy's symptoms. Schizoid personality disorder, choice C, is characterized by a lack of interest in social relationships, which is not a prominent feature in Suzy's case. Dissociative Identity Disorder, choice D, involves the presence of two or more distinct identities or personality states, which is not reflected in Suzy's symptoms.