Nokea
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
- A. Loss of hearing
- B. Paresthesia
- C. Muscle wasting
- D. Changes in vision
Correct Answer: B
Rationale: The correct answer is B: Paresthesia. Pernicious anemia is caused by a lack of vitamin B12, leading to nerve damage. Paresthesia, or tingling and numbness in the extremities, is a common symptom. This poses a risk to the client's safety as it may result in decreased sensation and coordination, increasing the risk of falls and injuries. Loss of hearing (A), muscle wasting (C), and changes in vision (D) are not directly associated with pernicious anemia and do not pose an immediate safety risk in this context.
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A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
- A. Loss of peripheral vision
- B. Inability to smell
- C. Deviation of the tongue from midline
- D. Disequilibrium with movement
Correct Answer: D
Rationale: The correct answer is D: Disequilibrium with movement. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for both hearing and balance. Impaired function of this nerve can result in symptoms such as dizziness, vertigo, and disequilibrium with movement. This is because the vestibular branch of the nerve is crucial for maintaining balance and spatial orientation.
Choice A, loss of peripheral vision, is not related to cranial nerve VIII but rather to cranial nerve II, the optic nerve. Choice B, inability to smell, is associated with cranial nerve I, the olfactory nerve. Choice C, deviation of the tongue from midline, is a sign of dysfunction of cranial nerve XII, the hypoglossal nerve.
In summary, the correct answer is D because impaired function of the vestibulocochlear nerve (cranial nerve VIII) would result in disequilibrium with movement, while the other choices are related to different cranial
A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessments should be the nurse's priority?
- A. Neurovascular assessment
- B. Braden scale
- C. Pain assessment
- D. Morse Fall Risk scale
Correct Answer: A
Rationale: The correct answer is A: Neurovascular assessment. This is the priority because the client is postoperative following ORIF of the femur, which puts them at risk for impaired circulation and nerve damage. The nurse needs to assess for signs of compromised blood flow or nerve function, such as changes in sensation, color, temperature, or pulse in the affected limb. If left unaddressed, neurovascular complications can lead to serious consequences like compartment syndrome or permanent damage. The other options are not the priority in this situation: B (Braden scale) assesses risk for pressure ulcers, C (Pain assessment) is important but not the priority over neurovascular status, and D (Morse Fall Risk scale) assesses fall risk which is important but not the priority immediately post-ORIF.
A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?
- A. I can take another dose after 2 minutes.
- B. I can put the tablet against my cheek and gum.
- C. I should chew the tablet before I swallow it.
- D. I should take this medication as soon as the pain begins.
Correct Answer: D
Rationale: The correct answer is D: "I should take this medication as soon as the pain begins." This is correct because nitroglycerin is a rapid-acting medication used to relieve chest pain associated with angina. Taking it at the onset of chest pain helps dilate blood vessels and improve blood flow to the heart muscle.
Choice A is incorrect because taking another dose after 2 minutes could lead to overdose and hypotension. Choice B is incorrect as the tablet should be placed under the tongue, not against the cheek and gum. Choice C is incorrect because nitroglycerin should not be chewed but allowed to dissolve under the tongue.
A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
- A. Administer analgesic medication.
- B. Increase the room temperature.
- C. Cleanse the client's wounds.
- D. Start IV with a large-bore needle.
Correct Answer: D
Rationale: The correct answer is D: Start IV with a large-bore needle. This is the priority intervention because fluid resuscitation is crucial in managing burn injuries to prevent hypovolemic shock. Starting an IV line allows for prompt administration of fluids and medications. Administering analgesic medication (A) can wait until after fluid resuscitation. Increasing room temperature (B) is not a priority in burn management. Cleansing wounds (C) can be done after fluid resuscitation. Starting the IV line with a large-bore needle (D) takes precedence over other interventions to stabilize the client's condition.
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?
- A. Gag reflex
- B. Warmth of extremities
- C. Temperature
- D. Level of pain
Correct Answer: A
Rationale: The correct answer is A: Gag reflex. The priority assessment for a client post-endoscopy with sedation is to ensure their airway is intact. The presence of a gag reflex indicates the airway protection mechanism is functional, reducing the risk of aspiration. Monitoring warmth of extremities, temperature, and pain level are important but secondary assessments compared to airway patency. Ensuring the client's safety and preventing respiratory compromise take precedence in this situation.