Nokea
A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement.
- A. Provide a warming pad (Aqua-pad or K-pad) to feet
- B. Medicate the client with a prescribed sedative
- C. Use a bed cradle to hold the covers off the feet
- D. Place warm blankets next to the client's feet
Correct Answer: D
Rationale: Warm blankets can help improve circulation and provide comfort without the risk of burns associated with heating pads.
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An 8-year-old from the former Soviet Union is brought to your office because of a heart murmur and dusty blue skin. He has marked clubbing of his fingers and toes, and his hematocrit is 70%. He has a grade 4/6 holosystolic murmur. His chest x-ray reveals a normal pulmonary blood flow as well as a right-sided aortic arch. What is the likely diagnosis?
- A. total anomalous venous return
- B. tetralogy of Fallot
- C. Eisenmenger syndrome
- D. transposition of the great vessels
Correct Answer: C
Rationale: Eisenmenger syndrome involves reversal of shunt direction due to long-standing pulmonary hypertension, explaining the cyanosis and clubbing.
A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation?
- A. Low-sodium soups.
- B. Over all fluid intake
- C. Tea and hot chocolate
- D. Citrus fruit juices
Correct Answer: C
Rationale: Tea and hot chocolate contain oxalates, which can contribute to the formation of calcium oxalate stones. Limiting these fluids helps prevent recurrence.
Short stature due to growth hormone deficiency:
- A. Is characteristically manifest in infancy
- B. May be secondary to irradiation to the skull
- C. Can be part of congenital hypopituitarism
- D. Is easily corrected
Correct Answer: B
Rationale: Growth hormone deficiency can result from cranial irradiation, which may damage the pituitary gland and impair hormone production.
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
- A. This is a routine surgery and the risk of death is very low.
- B. Would you like to speak with a chaplain before surgery?
- C. Tell me more about your concerns about the surgery.
- D. What support systems do you have to assist you?
Correct Answer: C
Rationale: Encouraging the client to express their concerns allows the nurse to provide emotional support and address specific fears.
A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care?
- A. Institute contact precautions for staff and visitors.
- B. Send wound drainage for culture and sensitivity.
- C. Monitor the client's white blood cell count.
- D. Administer broad-spectrum antibiotics before obtaining cultures.
Correct Answer: B
Rationale: MRSA requires contact precautions to prevent spread, culture and sensitivity testing is necessary to identify the specific organism, and WBC count should be monitored to assess for infection.