Nokea
A nurse is caring for a client who has been sitting in a chair for 3 hours. Which of the following problems is the client at risk for developing?
- A. Stasis of secretions
- B. Muscle atrophy
- C. Pressure ulcer
- D. Fecal impaction
Correct Answer: C
Rationale: The correct answer is C: Pressure ulcer. Prolonged sitting can lead to decreased blood flow to tissues, causing pressure ulcers. Stasis of secretions (A) is more related to respiratory issues. Muscle atrophy (B) is a result of inactivity but not typically seen after only 3 hours. Fecal impaction (D) is more related to constipation, not prolonged sitting.
You may also like to solve these questions
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all.
- A. The physical therapist didn't ambulate the client today
- B. The skin barrier's seal stays on in bed but loosens when the client stands.
- C. The client seemed to welcome having a 'day off' from physical therapy
- D. The wound care nurse will see the client later today
- E. The client ate all the food on her lunch tray
Correct Answer: A, B, D
Rationale: The correct choices to include in the change-of-shift report are A, B, and D. Choice A is important to communicate as it highlights that the physical therapist did not ambulate the client due to difficulties with the skin barrier and fistula drainage. Choice B is crucial as it explains the specific issue with the skin barrier, emphasizing that it stays intact when the client is supine but loosens when standing. Choice D is essential to include as it informs about the upcoming visit from the wound care nurse. Choices C and E, although relevant to the client's well-being, are not directly related to the current care plan and should not be included in the report.
A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all.
- A. A concave thoracic spine posteriorly
- B. An exaggerated lumbar curvature
- C. A concave lumbar spine posteriorly
- D. An exaggerated thoracic curvature
- E. Muscles slightly larger on his dominant side
Correct Answer: C, E
Rationale: Correct Answer: C, E
Rationale:
C: A concave lumbar spine posteriorly is expected in a young adult male due to the normal lordotic curve in the lumbar region for weight-bearing support.
E: Muscles slightly larger on his dominant side is an expected finding as asymmetry in muscle size and strength is common due to dominant limb use.
Incorrect Choices:
A: A concave thoracic spine posteriorly is not a normal finding and may indicate poor posture or spinal deformity.
B: An exaggerated lumbar curvature is not expected in a young adult male and may suggest a potential spinal issue.
D: An exaggerated thoracic curvature is not typical in a young adult male and may indicate abnormal spinal curvature.
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? Select all.
- A. Older adults are more prone to dehydration than younger adults.
- B. Older adults need the same amount of most vitamins and minerals as younger adults.
- C. Many older men and women need calcium supplementation.
- D. Older adults need more calories than they did when they were younger.
- E. Older adults should consume a diet low in carbohydrates.
Correct Answer: A, B, C
Rationale: The correct answer is A, B, and C.
A: Older adults are more prone to dehydration due to age-related physiological changes that decrease the body's ability to conserve water.
B: While older adults generally need the same amount of vitamins and minerals as younger adults, they may require higher amounts of certain nutrients like vitamin D and calcium.
C: Many older men and women may need calcium supplementation to prevent osteoporosis and maintain bone health.
Incorrect choices:
D: Older adults typically need fewer calories as they age due to decreased metabolism and physical activity.
E: There is no specific recommendation for older adults to consume a diet low in carbohydrates, as carbohydrates are an essential energy source.
A nurse is caring for a client who reports severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct Answer: D
Rationale: The correct answer is D: Illness. In this stage, the client is experiencing noticeable symptoms such as severe sore throat, pain when swallowing, and swollen lymph nodes. This indicates that the infection has progressed to the point where the body is actively fighting off the pathogen, resulting in the manifestation of symptoms. The other choices are incorrect because: A: Prodromal stage is characterized by mild, nonspecific symptoms. B: Incubation stage is the period between exposure to the pathogen and the onset of symptoms. C: Convalescence stage is the recovery period after the illness when symptoms start to improve.
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all.
- A. Apply suction while withdrawing the catheter
- B. Perform suctioning on a routine basis, Q2-3 hours
- C. Maintain medical asepsis during suctioning
- D. Use a new catheter for each suctioning attempt
- E. Limit suctioning to 2-3 attempts
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Apply suction while withdrawing the catheter - This guideline ensures effective removal of secretions without damaging the airway.
D: Use a new catheter for each suctioning attempt - Reusing catheters can introduce infection and compromise patient safety.
E: Limit suctioning to 2-3 attempts - Excessive suctioning can lead to hypoxia and damage to the airway. Limiting attempts is safer for the patient.
Incorrect Choices:
B: Performing suctioning on a routine basis, Q2-3 hours can be harmful as it may lead to unnecessary trauma to the airway and increased risk of infection.
C: Maintaining medical asepsis during suctioning is a general guideline but not specific to endotracheal suctioning.