Nokea
A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?
- A. Increased appetite
- B. Increased diarrhea
- C. Increased metabolic rate
- D. Altered nutrient metabolism
Correct Answer: D
Rationale: The correct answer is D: Altered nutrient metabolism. Immobility can lead to changes in nutrient metabolism due to decreased physical activity and muscle mass. The body may start breaking down muscle tissue for energy, leading to altered nutrient metabolism.
A: Increased appetite is not directly related to immobility and is unlikely to be a metabolic alteration seen in this patient.
B: Increased diarrhea is more likely related to gastrointestinal issues rather than a direct metabolic alteration due to immobility.
C: Increased metabolic rate is unlikely in an immobile patient as physical activity is decreased.
Therefore, D is the correct choice as it directly relates to the metabolic changes associated with immobility.
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Nurse is planning diversionary activities for children on inpatient peds unit. Which should nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.)
- A. Assembling puzzles
- B. Pulling wheeled toys
- C. Using musical toys
- D. Using finger paints
- E. Coloring with crayons
Correct Answer: A,C,E
Rationale: The correct activities for preschoolers are A, C, and E. A: Assembling puzzles promotes problem-solving and fine motor skills. C: Using musical toys enhances auditory skills and creativity. E: Coloring with crayons supports fine motor skills and creativity. B: Pulling wheeled toys may not be safe or developmentally appropriate. D: Using finger paints can be messy and may not be suitable for all children, especially those with sensory sensitivities.
Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, 'When I have difficulty breathing at night, I will...'
- A. Lie on my back with head & shoulders elevated on a pillow
- B. Lie flat on my stomach with head to one side
- C. Sit on side of my bed & rest my arms over pillows on top of my raised bedside table
- D. Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me
Correct Answer: C
Rationale: The correct answer is C: Sit on side of my bed & rest my arms over pillows on top of my raised bedside table. This position, known as orthopneic position, helps improve breathing by allowing the chest to expand fully, making it easier to take deep breaths. Sitting on the side of the bed and resting arms over pillows on a raised table helps to reduce the work of breathing.
A: Lie on my back with head & shoulders elevated on a pillow - This position may not provide as much relief in breathing as the orthopneic position.
B: Lie flat on my stomach with head to one side - This position can actually make breathing more difficult for someone with COPD.
D: Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me - This position may not be as effective in improving breathing compared to the orthopneic position.
By choosing option C, the client can effectively manage breathing difficulties associated with
Nurse is caring for client who presents with linear clusters of fluid-containing vesicles with some crusting. Which should nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The description of linear clusters of fluid-containing vesicles with some crusting is characteristic of herpes zoster, also known as shingles. This condition is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution along a dermatome is a key feature of herpes zoster. Allergic reaction (A) typically presents with generalized rash and itching, not linear clusters of vesicles. Ringworm (B) presents as circular, scaly lesions, not linear clusters of vesicles. Systemic lupus erythematosus (C) is an autoimmune disease that presents with a variety of symptoms, but not linear clusters of vesicles.
Nurse is caring for newly admitted client with history of falls. What is the priority action by the nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A: Complete fall-risk assessment. This is the priority action because it allows the nurse to identify specific risk factors contributing to the client's falls. By completing a fall-risk assessment, the nurse can implement appropriate interventions to prevent future falls. Choice B is incorrect because education should come after assessing the risk factors. Choice C is not the priority as the client's risk for falls needs to be addressed first. Choice D is irrelevant to addressing the immediate safety concern of falls.
A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?
- A. Moves patient's arm in a full circle
- B. Moves patient's arm across the body as far as possible
- C. Moves patient's arm behind body, keeping elbow straight
- D. Moves patient's arm until thumb is upward and lateral to head with elbow flexed
Correct Answer: D
Rationale: The correct answer is D. To perform external rotation of the shoulder, the nurse should move the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position optimally engages the external rotators of the shoulder joint, allowing for the desired movement. Choice A involves a full circle motion, which does not specifically target external rotation. Choice B focuses on adduction rather than external rotation. Choice C involves extension of the shoulder rather than external rotation. Therefore, the correct answer is D as it aligns with the anatomical movements required for external rotation of the shoulder joint.