Nokea
A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. As individuals age, there is a natural decline in muscle mass known as sarcopenia. This is due to a decrease in muscle fiber size and number. The nurse should include this alteration in the presentation because it is a common age-related musculoskeletal change that can lead to weakness, decreased mobility, and increased risk of falls in older adults.
Choices B, C, and D are incorrect because thickened vertebral disks, decreased chest width, and increased force of isometric contractions are not typical age-related musculoskeletal changes. Thickened vertebral disks are more associated with degenerative disc disease, decreased chest width is not a common age-related change, and increased force of isometric contractions is not a typical alteration seen in older adults.
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A nurse in an urgent care clinic is preparing to remove skin sutures from a client. Which of the following actions should the nurse take?
- A. Remove loose sutures first
- B. Cut below the suture knot
- C. Use clean bandage scissors
- D. Lift sutures from the skin with a sterile needle
Correct Answer: B
Rationale: Cutting below the suture knot prevents external contamination and reduces infection risk.
When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?
- A. Wrapping the cuff too loosely around the client's arm
- B. Positioning the client's arm above heart level
- C. Measuring blood pressure right after the client's mealtime
- D. Deflating the cuff too slowly
Correct Answer: B
Rationale: The correct answer is B: Positioning the client's arm above heart level. When the client's arm is positioned above heart level, it can lead to an artificially low blood pressure reading due to gravitational effects. This position can cause blood to pool in the arm, reducing the pressure in the arteries and resulting in an inaccurate measurement. This error is known as hydrostatic pressure error. Wrapping the cuff too loosely (choice A) can lead to an inaccurate reading due to inadequate compression of the artery. Measuring blood pressure right after a meal (choice C) can also affect the reading due to the body's response to food intake. Deflating the cuff too slowly (choice D) can result in a falsely elevated diastolic reading.
A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?
- A. Provide the client with a high fiber diet.
- B. Administer a soap-suds enema to cleanse the colon.
- C. Allow the perineal area to air dry after each stool.
- D. Apply an alcohol-free barrier to the perineal area after each stool.
Correct Answer: D
Rationale: An alcohol-free barrier protects the skin from irritation due to frequent stooling.
A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?
- A. Assist the guest to the floor and begin mouth-to-mouth resuscitation.
- B. Observe the guest before taking further action.
- C. Perform the Heimlich maneuver on the guest.
- D. Slap the guest on the back several times.
Correct Answer: C
Rationale: The correct answer is C: Perform the Heimlich maneuver on the guest. This is the appropriate action for a choking individual who is unable to speak or breathe. The Heimlich maneuver helps dislodge the obstruction from the airway by applying abdominal thrusts. It is crucial to act quickly in such situations to prevent further complications like loss of consciousness or asphyxiation.
Choice A is incorrect as mouth-to-mouth resuscitation is not appropriate for a choking victim. Choice B is incorrect as observing without taking immediate action can be dangerous if the individual's airway is completely blocked. Choice D is incorrect as slapping the back may not effectively dislodge the obstruction. It is essential to prioritize the Heimlich maneuver to clear the airway and restore breathing.
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)
- A. Apply ice to the ankle.
- B. Encourage range-of-motion exercises of the foot.
- C. Provide the client with a light snack.
- D. Apply a compression bandage.
- E. Elevate the foot.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- Apply ice to the ankle (A): Ice helps reduce swelling and inflammation by constricting blood vessels. It is essential for reducing pain and promoting healing.
- Apply a compression bandage (D): Compression helps reduce swelling and provides support to the injured area, promoting healing and preventing further damage.
- Elevate the foot (E): Elevating the foot above the heart level helps reduce swelling and promotes circulation, aiding in the healing process.
Incorrect Choices:
- Encourage range-of-motion exercises of the foot (B): Performing range-of-motion exercises on an injured ankle may worsen the injury and cause further damage.
- Provide the client with a light snack (C): Providing a snack is not a priority in this situation and does not contribute to the client's immediate care.