Nokea
A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?
- A. AÂ W client with a stroke with tube feedings
- B. A client with congestive heart failure complaining of nighttime dyspnea
- C. A client with a thoracotomy six months ago
- D. A client with Parkinson's disease
Correct Answer: B
Rationale: Nighttime dyspnea suggests acute heart failure exacerbation, requiring priority.
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A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:
- A. The client is at risk for opportunistic diseases.
- B. The client is no longer communicable.
- C. The client's viral load is extremely low so he is relatively free of circulating virus.
- D. The client's T-cell count is extremely low.
Correct Answer: C
Rationale: A viral load of 200 copies/ml is low, indicating effective treatment and minimal circulating virus.
To reduce the possibility of having a baby with a neural tube defect, the client should be told to increase her intake of folic acid. Dietary sources of folic acid include:
- A. Meat, liver, eggs
- B. Pork, fish, chicken
- C. Spinach, beets, cantaloupe
- D. Dried beans, sweet potatoes, Brussels sprouts
Correct Answer: D
Rationale: Folic acid is found in foods like dried beans, sweet potatoes, and Brussels sprouts. These help reduce the risk of neural tube defects like spina bifida when consumed before and during early pregnancy.
The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?
- A. Confirm that all staff members understand and comply with the treatment plan.
- B. Establish mutually agreed upon, realistic goals.
- C. Ensure that the potent reinforcers (rewards) are important to the client.
- D. Establish a fixed interval schedule for reinforcement.
Correct Answer: A
Rationale: to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program
The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?
- A. Application of a short inclusive spica cast
- B. Stabilization with a plaster-of-Paris cast
- C. Surgery with Kirschner wire implantation
- D. A gauze dressing only
Correct Answer: B
Rationale: A plaster-of-Paris cast is typically used to stabilize foot fractures, ensuring proper alignment and healing.
The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?
- A. Frothy hemoptysis
- B. Trachea shift toward the unaffected side of the chest
- C. Subcutaneous emphysema noted at the anterior chest
- D. Opening chest wound with a whistle sound emitting from the area
Correct Answer: B
Rationale: Tension pneumothorax causes a mediastinal shift, including tracheal deviation toward the unaffected side due to increased intrathoracic pressure.