Nokea
A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention?
- A. Capillary refill of fingers on right hand is 3 seconds
- B. Skin warm to touch and normally colored
- C. Client reports prickling sensation in the right hand
- D. Slight swelling of fingers of right hand
Correct Answer: C
Rationale: Client reports prickling sensation in the right hand. A prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.
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Which of the following is the primary force in sex education in a child's life?
- A. school nurse
- B. peers
- C. parents
- D. media
Correct Answer: C
Rationale: Parents are the primary influence on a child's sex education, providing foundational values and information. Other sources like peers and media are influential but secondary. Health Promotion and Maintenance
A 35-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate.
Which of the following would you most likely suspect?
- A. Atherosclerosis
- B. Diabetic neuropathy
- C. Autonomic neuropathy
- D. Somatic neuropathy
Correct Answer: C
Rationale: Autonomic neuropathy can impair bladder function, causing urinary retention in long-term diabetes.
B.C. is a 14-yr-old boy who was brought to the ER after he had sustained flame burns. He had been wearing masquerade costume during Halloween celebration when his costume was set ablaze by the lighted candles in the party room. He extinguished the fire by rolling on the floor. On admission, resuscitation was commenced with intravenous fluids, antibiotics, and wound dressing. On examination he was found to be a young man, not pale, but febrile (body temperature, 37.8°C). He was tachypneic, RR 26 per min, with audible breath sounds bilaterally. Burn assessment revealed a total body surface area involved of 30%, with mixed-thickness burns sparing some patchy areas of the back and the right upper limb. B.C. anterior chest was affected.
For the first 24 hours after hospitalization, the nurse should primarily observe him for
- A. wound sepsis.
- B. complain of pain.
- C. dyspnea or stridor.
- D. initiate IV therapy.
Correct Answer: C
Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia from irritation and edema of the respiratory passages and lungs.
Which client is at highest risk for developing a pressure ulcer?
- A. 23 year-old in traction for fractured femur
- B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- C. 75 year-old with left sided paresthesia who is incontinent of urine and stool
- D. 30 year-old who is comatose following a ruptured aneurysm
Correct Answer: C
Rationale: 75 year-old with left sided paresthesia who is incontinent of urine and stool. Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.
Which interventions are appropriate when caring for a client with acute thrombophlebitis?
- A. Apply cool soaks and keep the client's leg lower than the level of the heart
- B. Increase the client's activity level and encourage leg exercises
- C. Apply cool soaks and administer nitroglycerin
- D. Apply warm soaks and elevate the client's legs higher than the level of the heart
Correct Answer: D
Rationale: To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time.