Nokea
When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
- A. Competent venous valves.
- B. Decreased blood volume.
- C. Increase in muscular activity.
- D. Increased venous pressure.
Correct Answer: D
Rationale: The correct answer is 'Increased venous pressure.' In peripheral vascular disease (PVD), impaired blood flow leads to increased venous pressure in the lower extremities, causing fluid to leak out of the blood vessels and accumulate as edema. Choice A, 'Competent venous valves,' is incorrect because in PVD, the venous valves may be incompetent, contributing to venous pooling and edema. Choice B, 'Decreased blood volume,' is incorrect as PVD is associated with impaired blood flow rather than reduced blood volume. Choice C, 'Increase in muscular activity,' is incorrect as it does not directly relate to the development of edema in PVD.
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A client with chronic renal failure is receiving sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hyperkalemia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: Correct Answer: The correct answer is C, 'Hyperkalemia.' Sodium polystyrene sulfonate (Kayexalate) is a medication used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the intestines, leading to potassium removal from the body. Therefore, the nurse should monitor the client for changes in potassium levels to assess the effectiveness of the medication and prevent potential complications related to hyperkalemia. Choice A, 'Hyponatremia,' is incorrect as Kayexalate does not primarily affect sodium levels. Choice B, 'Hypokalemia,' is incorrect as Kayexalate is used to treat high potassium levels, not low. Choice D, 'Hypocalcemia,' is incorrect as Kayexalate does not directly impact calcium levels.
To assess the quality of an adult client's pain, what approach should the nurse use?
- A. Observe body language and movement.
- B. Ask the client to describe the pain.
- C. Identify effective pain relief measures.
- D. Provide a numeric pain scale.
Correct Answer: B
Rationale: The correct answer is to ask the client to describe the pain. This approach allows the nurse to gather subjective information directly from the client, such as the quality, intensity, location, and factors that aggravate or alleviate the pain. Observing body language and movement (Choice A) can provide additional cues but may not fully capture the client's pain experience. Identifying effective pain relief measures (Choice C) and providing a numeric pain scale (Choice D) are important aspects of pain management but do not directly assess the quality of the client's pain.
To reduce the risk of pulmonary complications for a client with ALS, which intervention should the nurse implement?
- A. Perform chest physiotherapy
- B. Teach the client breathing exercises
- C. Initiate passive range of motion exercises
- D. Establish a regular bladder routine
Correct Answer: A
Rationale: Performing chest physiotherapy is the most appropriate intervention to reduce the risk of pulmonary complications in clients with ALS. Chest physiotherapy helps mobilize and clear respiratory secretions, improving lung function and reducing the risk of complications such as pneumonia. Teaching breathing exercises (Choice B) may be beneficial for some clients, but chest physiotherapy is more specifically targeted at managing pulmonary issues in ALS. Initiating passive range of motion exercises (Choice C) and establishing a regular bladder routine (Choice D) are important interventions in ALS care but are not directly related to reducing the risk of pulmonary complications.
In a patient with asthma, which of the following is a primary goal of treatment?
- A. Improving oxygenation.
- B. Reducing inflammation.
- C. Improving airflow.
- D. Reducing airway constriction.
Correct Answer: C
Rationale: The primary goal in the treatment of asthma is to improve airflow. Asthma is characterized by airway inflammation, constriction, and increased mucus production, leading to airflow limitation. Improving airflow helps ensure adequate oxygenation and reduces symptoms. While reducing inflammation and airway constriction are important aspects of asthma management, the primary goal is to optimize airflow to improve respiratory function and quality of life.
Which of the following conditions is most commonly associated with a high risk of stroke?
- A. Hypertension.
- B. Diabetes.
- C. Obesity.
- D. Smoking.
Correct Answer: A
Rationale: Hypertension is the correct answer. Hypertension, also known as high blood pressure, is a major risk factor for stroke because it puts increased pressure on blood vessels in the brain, making them more prone to damage and increasing the likelihood of a stroke. While diabetes, obesity, and smoking are also risk factors for stroke, hypertension is the most commonly associated condition with a high risk of stroke due to its direct impact on the blood vessels.