Nokea
A nurse is caring for a patient with a history of stroke. The nurse should monitor for which of the following complications?
- A. Pulmonary embolism.
- B. Deep vein thrombosis (DVT).
- C. Hypertension.
- D. Hyperglycemia.
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. Monitoring for DVT is crucial to prevent life-threatening complications like pulmonary embolism. Pulmonary embolism (A) is a potential complication of DVT but not the most direct concern. Hypertension (C) is a common condition but not directly linked to a history of stroke. Hyperglycemia (D) is more commonly associated with diabetes rather than stroke history. Monitoring for DVT in stroke patients is essential for early detection and intervention.
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Why must a nurse avoid disrupting bloodstains or tears on the clothing of a trauma client?
- A. The clothing is the property of another
- B. It facilitates repair and salvage of the clothing
- C. The clothing is potential evidence with legal implications
- D. It decreases trauma to family members
Correct Answer: C
Rationale: The correct answer is C because the clothing of a trauma client could potentially be considered evidence with legal implications. Preserving the bloodstains or tears on the clothing maintains the integrity of the evidence for forensic investigation or legal proceedings. Disrupting the bloodstains or tears could compromise the evidence and hinder any potential investigation or legal case. Choices A, B, and D are incorrect because the primary concern in this scenario is the legal implications and preservation of evidence, not ownership, repair, salvage, or minimizing trauma to family members.
Which quadrant of the abdomen is tender in suspected appendicitis?
- A. upper right
- B. upper left
- C. lower right
- D. lower left
Correct Answer: C
Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.
A nurse is caring for a patient with diabetes who is experiencing diabetic neuropathy. The nurse should educate the patient to prioritize which of the following?
- A. Inspecting feet daily for signs of injury.
- B. Exercising to increase circulation.
- C. Taking pain medication for relief.
- D. Increasing protein intake to support healing.
Correct Answer: A
Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial in diabetic neuropathy to prevent complications such as infections and ulcers. By inspecting the feet daily, the patient can identify any injuries early and seek prompt treatment. Exercising (choice B) is important, but not the top priority. Taking pain medication (choice C) only addresses symptoms, not the root cause. Increasing protein intake (choice D) may be beneficial for healing, but foot inspection is more directly related to preventing complications in diabetic neuropathy.
A patient keeps saying, "I feel hot. Hot, cot, rot, tot, got. I'm a spot.' This is an illustration of:
- A. Blocking.
- B. Clanging.
- C. Echolalia.
- D. Neologism.
Correct Answer: B
Rationale: The correct answer is B: Clanging. Clanging refers to the phenomenon where words are chosen based on sound rather than meaning. In this case, the patient's speech demonstrates a pattern of words that rhyme or have similar sounds, despite lacking coherence or logical connection. This behavior is commonly seen in individuals with conditions like schizophrenia.
Incorrect choices:
A: Blocking - Blocking refers to sudden interruption or cessation of speech. This does not apply to the scenario described.
C: Echolalia - Echolalia involves repetition of words or phrases spoken by others, not self-generated word patterns like in the scenario.
D: Neologism - Neologism refers to the creation of new words or phrases with unique meanings, which is not reflected in the patient's speech pattern.
Which intervention should the nurse implement for a client who is experiencing a seizure?
- A. Place the client on their side and protect their head
- B. Loosen the client's clothing and ensure safety
- C. Monitor the client's airway and give oxygen
- D. Administer antiepileptic medications
Correct Answer: D
Rationale: The correct answer is D, administering antiepileptic medications. This is because during an active seizure, the priority is to stop the seizure activity. Antiepileptic medications are specifically designed to prevent or reduce the frequency and intensity of seizures. Placing the client on their side and protecting their head (choice A) is important for safety but does not address stopping the seizure. Loosening clothing and ensuring safety (choice B) is also important but does not directly address the seizure itself. Monitoring airway and giving oxygen (choice C) is crucial but does not actively stop the seizure. Therefore, administering antiepileptic medications is the most appropriate intervention to address the root cause of the seizure.