Nokea
A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
- A. A client who has Guillain-Barré syndrome
- B. A client who has systemic sclerosis
- C. A client who has amyotrophic lateral sclerosis (ALS)
- D. A client who has a lumbosacral spinal tumor
Correct Answer: D
Rationale: The correct answer is D: a client who has a lumbosacral spinal tumor. This client may require meal assistance due to potential physical limitations caused by the tumor. The nurse should delegate this task to the AP because it falls within their scope of practice.
Choice A (Guillain-Barré syndrome), Choice B (systemic sclerosis), and Choice C (ALS) all involve neuromuscular conditions that can affect the client's ability to swallow or chew, and thus meal assistance should be provided by a higher-level healthcare provider.
In summary, the correct answer is D because the client with a lumbosacral spinal tumor is more likely to need assistance with meals due to physical limitations, and the AP is appropriate for this task. The other choices involve conditions where meal assistance may require more specialized care.
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A nurse is attending a social event when another guest coughs weakly once, grasps his throat, and cannot talk. Which of the following actions should the nurse take?
- A. Perform the Heimlich maneuver.
- B. Slap the client on the back several times.
- C. Assist the client to the floor and begin mouth-to-mouth resuscitation.
- D. Observe the client before taking further action.
Correct Answer: A
Rationale: The correct answer is A: Perform the Heimlich maneuver. This action is appropriate for a choking individual who is unable to speak, cough weakly, and grasp their throat, indicating a partial airway obstruction. The Heimlich maneuver is designed to dislodge the obstruction by applying abdominal thrusts. This is the most effective intervention in this scenario to clear the airway and restore breathing. Slapping the client on the back (B) may not effectively remove the obstruction. Mouth-to-mouth resuscitation (C) is not indicated for a conscious choking person. Observing the client (D) without taking immediate action can lead to a worsening situation.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
- A. Dependent rubor
- B. Thick, deformed toenails
- C. Hair loss
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice B) and hair loss (choice C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hyperglycemia
- C. Dehydration
- D. Polyphagia
Correct Answer: C
Rationale: The correct answer is C: Dehydration. In diabetes insipidus, there is a deficiency of antidiuretic hormone leading to excessive urine output, causing dehydration. Bradycardia (A) is not typically associated. Hyperglycemia (B) is seen in diabetes mellitus, not diabetes insipidus. Polyphagia (D) is excessive hunger, which is not a common symptom of diabetes insipidus.
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?
- A. Painful urination
- B. Urge incontinence
- C. Critically elevated prostate-specific antigen (PSA) level
- D. Difficulty starting the flow of urine
Correct Answer: D
Rationale: The correct answer is D: Difficulty starting the flow of urine. This is an expected finding in a client with benign prostatic hyperplasia (BPH) due to the enlargement of the prostate gland, which can obstruct the urethra and impede the flow of urine. This commonly leads to hesitancy or difficulty initiating urination.
- A: Painful urination is not typically associated with BPH, as it is more commonly seen in conditions like urinary tract infections.
- B: Urge incontinence is not a typical finding in BPH; it is more commonly seen in conditions like overactive bladder.
- C: Critically elevated prostate-specific antigen (PSA) levels are not a direct symptom of BPH but may be used for screening and monitoring prostate cancer.
In summary, difficulty starting the flow of urine is the most relevant finding in BPH due to the mechanical obstruction caused by the enlarged prostate gland.
A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?
- A. Hypophosphatemia
- B. Hyperkalemia
- C. Hypercalcemia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. In prerenal AKI, decreased blood flow to the kidneys leads to reduced filtration and impaired excretion of potassium, resulting in hyperkalemia. Hypophosphatemia (A), hypercalcemia (C), and hypernatremia (D) are not typically associated with prerenal AKI. In prerenal AKI, there is usually no significant change in phosphate levels, calcium levels are typically normal or low due to volume depletion, and sodium levels may be normal or decreased due to reduced renal perfusion.