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A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
- A. Tip of the toes
- B. Medial malleolus (ankle)
- C. Ball of the foot
- D. Heel of the foot
Correct Answer: B
Rationale: The correct answer is B: Medial malleolus (ankle). Venous ulcers commonly occur in areas where there is poor circulation, such as the lower legs. The medial malleolus is a common site for venous ulcers in individuals with chronic venous insufficiency due to pooling of blood in the lower extremities. Assessing this area is crucial for early detection and appropriate management. Choices A, C, and D are incorrect as venous ulcers typically develop in areas with high venous pressure and poor circulation, such as the lower legs, not at the tip of the toes, ball of the foot, or heel.
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A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Right lower quadrant pain
- B. Rebound tenderness
- C. Nausea and vomiting
- D. Elevated blood glucose
- E. Hypotension
Correct Answer: A, B, C
Rationale: The correct manifestations for suspected appendicitis are A, B, and C. A is correct as appendicitis typically presents with right lower quadrant pain due to inflammation of the appendix. B is correct as rebound tenderness, which is pain upon release of pressure on the abdomen, is a classic sign of appendicitis. C is correct as nausea and vomiting are common symptoms due to irritation of the gastrointestinal tract. D and E are incorrect as elevated blood glucose and hypotension are not commonly associated with appendicitis.
A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate independently.
- B. Turn the client by log rolling with a turning sheet.
- C. Position the client in a high Fowlers position.
- D. Apply a heating pad to the lower back.
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. This is the correct intervention because after a lumbar laminectomy, it is crucial to protect the surgical site and avoid bending or twisting the spine. Log rolling with a turning sheet helps maintain proper alignment and prevent injury to the surgical area.
Choice A is incorrect because encouraging the client to ambulate independently may put stress on the surgical area. Choice C is incorrect as positioning the client in a high Fowler's position may also strain the spine. Choice D is incorrect because applying a heating pad to the lower back can increase the risk of burns and should be avoided near a surgical site.
A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurses priority?
- A. Monitor urine output.
- B. Assess level of consciousness.
- C. Check ABGs.
- D. Monitor for signs of withdrawal.
Correct Answer: C
Rationale: The correct answer is C: Check ABGs. In this scenario, monitoring the client's arterial blood gases (ABGs) is the priority assessment because heroin toxicity can lead to respiratory depression and impaired gas exchange. ABGs provide crucial information about the client's oxygenation and ventilation status, which is essential for managing mechanical ventilation and preventing respiratory complications. Monitoring urine output (A) is important but not the priority in a client with potential respiratory compromise. Assessing level of consciousness (B) is significant, but ensuring adequate oxygenation takes precedence. Monitoring for signs of withdrawal (D) is important but not as urgent as assessing respiratory status.
A nurse is providing teaching to a client about strategies to manage menopausal symptoms. Which of the following instructions should the nurse include in the teaching?
- A. Use water-based lubricant during intercourse to reduce discomfort.
- B. Take estrogen supplements without consulting a provider.
- C. Limit calcium intake to reduce bloating.
- D. Avoid all physical activity to conserve energy.
Correct Answer: A
Rationale: The correct answer is A: Use water-based lubricant during intercourse to reduce discomfort. This instruction is important for managing menopausal symptoms like vaginal dryness and discomfort during intercourse. Water-based lubricants can help alleviate these symptoms. Option B is incorrect as taking estrogen supplements without consulting a provider can have risks and side effects. Option C is incorrect because limiting calcium intake is not recommended during menopause, as calcium is important for bone health. Option D is incorrect as avoiding physical activity can worsen menopausal symptoms and impact overall health.
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?
- A. I feel overwhelmed and unsure if I can handle this responsibility.
- B. I changed the floor plan of our home to accommodate my fathers wheelchair.
- C. I wish my siblings would help more with our parents care.
- D. I often feel resentful about the extra responsibilities.
Correct Answer: B
Rationale: The correct answer is B. Changing the floor plan of the home to accommodate the father's wheelchair demonstrates acceptance of the caregiving role. This action shows that the client is willing to make necessary adjustments for their parents' needs, indicating a commitment to the role change.
A: Feeling overwhelmed and unsure indicates resistance to the role change.
C: Wishing for siblings' help suggests a desire to share responsibilities, not necessarily acceptance.
D: Feeling resentful points towards negative emotions, which do not align with acceptance.