Nokea
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Right lower quadrant pain
- B. Rebound tenderness
- C. Nausea and vomiting
- D. Elevated blood glucose
- E. Hypotension
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
You may also like to solve these questions
A nurse is caring for a 75-year-old client who is admitted to the medical-surgical unit. Which of the following findings indicate the client is most likely experiencing deep vein thrombosis (DVT)?
- A. Unilateral right lower extremity swelling and warmth below the knee
- B. Pain level as 2 on a scale of 0 to 10
- C. Ambulating in hallway with assistance
- D. Not wearing sequential compression devices
Correct Answer: A
Rationale: The correct answer is A. Unilateral right lower extremity swelling and warmth below the knee are classic signs of deep vein thrombosis (DVT). The swelling occurs due to blood clot formation, leading to impaired venous return and warmth due to inflammation. Choice B is incorrect because pain level alone is not a specific indicator of DVT. Choice C is incorrect as ambulating with assistance does not directly relate to DVT. Choice D is incorrect as not wearing sequential compression devices does not definitively indicate DVT.
A nurse is performing a risk assessment for a client. Which of the following factors should the nurse identify as increasing the clients risk for falls?
- A. The client had cataract surgery 1 day ago.
- B. The client uses a hearing aid.
- C. The client has a history of hypertension.
- D. The client has a history of constipation.
Correct Answer: A
Rationale: Correct Answer: A. The client had cataract surgery 1 day ago.
Rationale: Cataract surgery can lead to temporary visual impairment, affecting depth perception and balance, increasing fall risk.
Summary:
B: Using a hearing aid does not directly increase fall risk.
C: History of hypertension does not directly increase fall risk for falls.
D: History of constipation does not directly increase fall risk for falls.
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
- A. Peripheral neuropathy
- B. Hypertension
- C. Retinopathy
- D. Stroke
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes mellitus, microvascular complications involve damage to small blood vessels. Retinopathy specifically affects the blood vessels in the retina, leading to vision problems. Peripheral neuropathy (A) is a macrovascular complication affecting nerves. Hypertension (B) is a common comorbidity in diabetes but not a direct microvascular complication. Stroke (D) is a macrovascular complication involving larger blood vessels in the brain. Therefore, the presence of retinopathy is a clear indication of a microvascular complication in a client with type 2 diabetes mellitus.
A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
- A. Tip of the toes
- B. Medial malleolus (ankle)
- C. Ball of the foot
- D. Heel of the foot
Correct Answer: B
Rationale: The correct answer is B: Medial malleolus (ankle). Venous ulcers commonly occur in areas where there is poor circulation, such as the lower legs. The medial malleolus is a common site for venous ulcers in individuals with chronic venous insufficiency due to pooling of blood in the lower extremities. Assessing this area is crucial for early detection and appropriate management. Choices A, C, and D are incorrect as venous ulcers typically develop in areas with high venous pressure and poor circulation, such as the lower legs, not at the tip of the toes, ball of the foot, or heel.
A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions should the nurse include in the teaching?
- A. Increase your intake of protein to 1 to 1.5 grams per kilogram per day.
- B. Reduce your fluid intake to 1L per day.
- C. Increase sodium intake to prevent hypotension.
- D. Monitor blood glucose levels daily.
Correct Answer: A
Rationale: The correct answer is A: Increase your intake of protein to 1 to 1.5 grams per kilogram per day. This is because patients undergoing hemodialysis often experience protein loss during the process. Adequate protein intake helps maintain muscle mass and supports overall health. Option B is incorrect as fluid restriction is typically recommended for patients on hemodialysis due to impaired fluid removal by the kidneys. Option C is incorrect as increasing sodium intake can lead to fluid retention and exacerbate hypertension, a common complication in chronic kidney disease. Option D is not directly related to hemodialysis and is more pertinent to diabetes management.