Nokea
A nurse is collecting data from a client who has Cushing's syndrome. Which of the following findings should the nurse expect?
- A. Jaundice
- B. Muscle rigidity
- C. Weight loss
- D. Easily bruised
Correct Answer: D
Rationale: Easy bruising is expected in Cushing's syndrome due to excess cortisol thinning the skin and weakening blood vessels. Jaundice, rigidity, and weight loss are not typical.
You may also like to solve these questions
A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?
- A. Discard soiled wound care supplies in a trash receptacle outside the client's room.
- B. Administer antibiotic therapy before culturing the client's wound.
- C. Place the client in a private room with a private bathroom.
- D. Instruct visitors to perform hand hygiene for 5 seconds after leaving the client's room.
Correct Answer: C
Rationale: A private room with a private bathroom helps control infection spread from a foul-smelling, infectious wound. Supplies should be discarded in biohazard containers, cultures taken before antibiotics, and hand hygiene should be thorough, not just 5 seconds.
A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee stiffness upon ambulation. Which of the following interventions should the nurse include in the plan of care?
- A. Apply moist heat prior to ambulation.
- B. Delay ambulation until the next day
- C. Use a continuous passive motion machine
- D. Rest in a soft chair
- E. Apply cold packs.
- F. Increase weight-bearing exercise.
- G. Avoid all movement.
Correct Answer: A
Rationale: Moist heat reduces stiffness and improves mobility in osteoarthritis.
A nurse is reviewing a client's medical history to identify risk factors for osteoporosis. The nurse should identify that which of the following findings is a risk factor for developing osteoporosis?
- A. Age 45 years
- B. Regular aerobic exercise
- C. Uses NSAIDS for pain relief
- D. Smokes cigarettes
Correct Answer: D
Rationale: Smoking is a known risk factor for osteoporosis as it reduces bone density. Age 45 isn't a strong risk unless postmenopausal, exercise helps, and NSAIDs aren't a direct risk.
A nurse is collecting data from a client who has a subdural hematoma following a motor-vehicle crash. For which of the following findings should the nurse identify that the client is experiencing an increase in intracranial pressure?
- A. The client has a delayed response to verbal commands.
- B. The client has ecchymosis around the eyes.
- C. The client is unable to remember details of the motor-vehicle crash.
- D. The client reports ringing in the ears.
Correct Answer: A
Rationale: Delayed verbal response indicates rising intracranial pressure (ICP) affecting brain function. Ecchymosis and amnesia are hematoma signs, and ringing ears isn't specific to ICP.
A nurse is collecting data from a client who has heart failure. Which of the following findings should the nurse report to the provider?
- A. Activity tolerance
- B. Weight
- C. Chest x-ray results
- D. Echocardiogram results
Correct Answer: B
Rationale: Heart failure management hinges on detecting decompensation, where weight gain from fluid retention is a red flag. Sudden increases (e.g., 2-3 lbs overnight) signal worsening congestion, necessitating prompt provider action like diuretic adjustment. Activity tolerance reflects functional status but is subjective and less urgent unless acutely dropping. Chest x-ray results show pulmonary edema or cardiomegaly, but weight offers earlier, actionable data. Echocardiogram results assess heart function long-term, not immediate changes. Daily weight monitoring is a cornerstone of heart failure care fluid overload precedes symptoms like dyspnea, making it the priority to report. This aligns with clinical guidelines (e.g., ACC/AHA), enabling timely intervention to prevent hospitalization or acute failure, emphasizing its critical role in ongoing assessment.