Nokea
A client with rheumatoid arthritis states, 'I can't do my household chores without becoming tired. My knees hurt whenever I walk.' Which nursing diagnosis would be most appropriate?
- A. Activity intolerance related to fatigue and pain.
- B. Self-care deficit related to increasing joint pain.
- C. Selective coping related to chronic pain.
- D. Disturbed body image related to fatigue and joint pain.
Correct Answer: A
Rationale: The client's symptoms of fatigue and knee pain directly contribute to activity intolerance, making this the most appropriate nursing diagnosis.
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Which of the following individuals should the nurse consider to have the highest priority for receiving seasonal influenza vaccination?
- A. A 60-year-old man with a hiatal hernia.
- B. A 36-year-old woman with three children.
- C. A 50-year-old woman caring for a spouse with cancer.
- D. A 60-year-old woman with osteoarthritis.
Correct Answer: C
Rationale: The 50-year-old caring for an immunocompromised spouse is the highest priority for influenza vaccination to prevent transmission. Others have lower risk profiles.
A client is admitted to the emergency department complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to:
- A. Maintain circulation
- B. Manage pain
- C. Prepare the client for emergency surgery
- D. Teach postoperative breathing exercises
Correct Answer: C
Rationale: A large abdominal aortic aneurysm with severe pain suggests impending rupture, requiring emergency surgery to prevent catastrophic bleeding. Preparing the client for surgery is the primary goal, as it addresses the life-threatening condition. Circulation, pain, and breathing exercises are managed perioperatively.
A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the unlicensed assistive personnel (UAP) to do during postmortem care? Select all that apply.
- A. Remove all tubes and I.V. lines.
- B. Cover the body with a sheet.
- C. Notify the family.
- D. Transport the body to the morgue.
- E. Notify the chaplain.
Correct Answer: B,D
Rationale: UAP can cover the body and transport it to the morgue. Removing tubes may be restricted due to forensic needs, and notifying family or chaplain is typically a nurse's responsibility.
The nurse is teaching an older adult client with a history of heat exhaustion. Which of the following statements by the client indicates a need for further teaching?
- A. I should take a cool shower after being outdoors in very hot weather.
- B. I can place ice packs on my neck, chest, and stomach after being outdoors in the heat.
- C. I should wear lightweight, light-colored, and loose-fitting clothing when working outside on very hot days.
- D. I should consume water and take my salt tablets when I am outside gardening on very hot days.
Correct Answer: B
Rationale: Using ice packs can cause vasoconstriction or tissue damage and is not recommended for heat exhaustion. Cool showers (A), appropriate clothing (C), and hydration (D) are correct, but salt tablets are unnecessary with adequate diet and hydration.
The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet?
- A. Hamburger, salad, and milkshake.
- B. Baked liver, green beans, and coffee.
- C. Spaghetti with tomato sauce, salad, and coffee.
- D. Fried chicken, green beans, and skim milk.
Correct Answer: C
Rationale: Spaghetti with tomato sauce, salad, and coffee is low in cholesterol, unlike hamburger, liver, or fried chicken, which contain higher cholesterol or saturated fats.