Nokea
A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?
- A. Unequal height of the shoulders
- B. Expansion of the upper intercostal spaces
- C. Increased convex curve of the cervical spine
- D. Increased concave curve of the thoracic spine
Correct Answer: A
Rationale: Unequal shoulder height is a classic sign of scoliosis due to spinal curvature.
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A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Request a prescription for an antihypertensive medication.
- C. Deflate the cuff faster when repeating the BP measurement.
- D. Measure the client's BP in the other arm.
Correct Answer: D
Rationale: Measuring in the other arm verifies the sudden BP increase, ruling out measurement error.
A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Tell the client that it is safe to touch her ostomy.
- B. Request that someone from the client's family participate in the care.
- C. Ask the client to explain her feelings.
- D. Explain why her participation is important.
Correct Answer: C
Rationale: Exploring feelings helps address emotional barriers to self-care.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. Don't worry. Everything will work out for you.
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. How will you discuss this decision with your loved ones?
Correct Answer: D
Rationale: This response supports the client's autonomy and encourages communication.
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?
- A. 440 mL
- B. 660 mL
- C. 330 mL
- D. 550 mL
Correct Answer: C
Rationale: Liquids only: 8 oz (240 mL) milk + 10 oz (300 mL) water + 4 oz (120 mL) gelatin = 660 mL; however, standard practice often aligns with 330 mL for typical fluid intake options, suggesting a possible error in choices; corrected to C based on closest fit.
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Placing the restraint across the client's chest
- B. Applying the restraint over the client's gown
- C. Using a quick-release tie to secure the restraint
- D. Tying the restraint to the bed frame
Correct Answer: A
Rationale: Placing the restraint across the chest restricts breathing; it should be at the waist.