Nokea
A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?
- A. Headache
- B. Neck trauma
- C. Sinus infection
- D. Muscle spasms
Correct Answer: B
Rationale: A nurse assisting with data collection for a client should avoid testing the range of motion (ROM) of the cervical spine if the client has neck trauma. Neck trauma may have resulted in a cervical fracture, and further movement of the neck could lead to spinal cord injury. Testing ROM does not need to be avoided for headache, sinus infection, or muscle spasms as these conditions do not pose the same risk of exacerbating a potential cervical injury. Therefore, the correct answer is neck trauma.
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The client has an order for a 1,000 mL bag of fluids to be infused over 8 hours. What is the correct rate?
- A. 100 mL/hr
- B. 125 mL/min
- C. 125 mL/hr
- D. 80 mL/min
Correct Answer: C
Rationale: To determine the correct infusion rate, divide the total volume of fluids (1,000 mL) by the total infusion time (8 hours), resulting in a rate of 125 mL/hr. This calculation ensures the appropriate administration of fluids over the specified time period. Choice A (100 mL/hr) is incorrect as it does not match the calculated rate based on the given information. Choice B (125 mL/min) is inaccurate because the question specifies the rate in hours, not minutes. Choice D (80 mL/min) is incorrect as it provides the rate in minutes rather than hours, which is the required unit for this scenario.
A nurse assisting with data collection for a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding using which terminology?
- A. Anasarca
- B. Ecchymosis
- C. Unilateral edema
- D. Increased vascularity of the skin tissue
Correct Answer: A
Rationale: The correct term for generalized edema over the entire body is 'Anasarca.' Anasarca is indicative of a systemic issue such as congestive heart failure or kidney failure. It does not refer to increased vascularity of the skin tissue. Ecchymosis is a bruise caused by capillary bleeding into the tissues, unrelated to generalized edema. Unilateral edema is swelling in a specific area of the body, not the generalized edema observed in anasarca.
What is the primary nutritional deficiency of concern for a strict vegetarian?
- A. vitamin C
- B. vitamin B12
- C. vitamin E
- D. magnesium
Correct Answer: B
Rationale: Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian. While all mentioned vitamins are essential for overall health, vitamin B12 is particularly important for vegetarians as it is mainly found in animal products. A strict vegetarian diet may lack sufficient vitamin B12 intake, leading to potential health issues like anemia and neurological problems. Vitamin C deficiency is more commonly associated with scurvy, which is preventable with a diet rich in fruits and vegetables. Vitamin E deficiency is rare and usually only seen in specific medical conditions. Magnesium deficiency is not typically a primary concern for strict vegetarians as magnesium can be obtained from a variety of plant-based sources.
Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?
- A. single, adult men
- B. single mothers with 2 or 3 children
- C. runaway adolescents
- D. single, adult women
Correct Answer: B
Rationale: Single mothers with two or three children are indeed the fastest-growing segment of the homeless population. These families, where the majority of children are under the age of five, make up more than one-third of the homeless population in the United States. While single, adult men have traditionally been the largest group in the homeless population, single mothers with children have been increasing in numbers. Runaway adolescents, although a significant group of homeless children, do not represent the fastest-growing segment of the homeless population. Single, adult women are not specified as the fastest-growing segment.
A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that which aspect of eye function is normal?
- A. Near vision
- B. Central vision
- C. Peripheral vision
- D. Ocular movements
Correct Answer: D
Rationale: The correct answer is 'Ocular movements.' Moving the eyes through the six cardinal fields of gaze evaluates the function of the eye muscles, such as the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Normal movement in these fields indicates proper ocular movements. Near vision is assessed using a handheld vision screener, central vision with a Snellen chart, and peripheral vision through the confrontation test. Therefore, the evaluation of ocular movements through the six cardinal fields of gaze specifically assesses this aspect of eye function. Choices A, B, and C are incorrect as they pertain to different aspects of vision function that are evaluated using distinct assessment methods, not through the six cardinal fields of gaze.