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A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?
- A. Determine the client's perception of his body image.
- B. Encourage the client to talk about his feelings regarding his body image.
- C. Discuss alternative coping strategies to relieve stress he feels about his body image.
- D. Assist the client to acknowledge he has a distorted body image.
Correct Answer: A
Rationale: Assessing the client's perception of their body image is the first step in understanding their emotional and psychological response.
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A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?
- A. Lower the height of the solution container.
- B. Encourage the client to bear down.
- C. Allow the client to expel some fluid before continuing.
- D. Stop the enema and document that the client did not tolerate the procedure.
Correct Answer: A
Rationale: Correct Answer: A: Lower the height of the solution container.
Rationale: Lowering the height of the solution container will decrease the rate of flow, reducing the pressure and volume of the solution entering the client's colon. This can help alleviate the cramping sensation by slowing down the administration of the enema.
Summary of other choices:
B: Encouraging the client to bear down may increase intra-abdominal pressure, worsening the cramping sensation.
C: Allowing the client to expel some fluid before continuing may not address the root cause of the discomfort, which is the rapid influx of solution.
D: Stopping the enema and documenting that the client did not tolerate the procedure does not actively address the client's discomfort or provide immediate relief.
A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?
- A. Brachial
- B. Carotid
- C. Femoral
- D. Popliteal
Correct Answer: B
Rationale: The correct answer is B: Carotid. Checking the carotid pulse bilaterally simultaneously can lead to a temporary decrease in blood flow to the brain, potentially causing dizziness or fainting. It is important to assess one carotid pulse at a time to ensure adequate blood supply to the brain. Checking the brachial, femoral, and popliteal pulses bilaterally at the same time is safe as it does not pose a risk of compromising blood flow to critical organs.
A nurse is performing pulmonary hygiene for a client who has pneumonia. The nurse should have the client lie on his back with his head elevated to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Elevating the head improves lung expansion and drainage of anterior lung segments.
A nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?
- A. 108/60 mm Hg
- B. 128/88 mm Hg
- C. 154/96 mm Hg
- D. 164/104 mm Hg
Correct Answer: C
Rationale: The correct answer is C (154/96 mm Hg) for stage 1 hypertension. Stage 1 hypertension is defined as systolic blood pressure ranging from 130-139 mm Hg or diastolic blood pressure ranging from 80-89 mm Hg. Option C falls within this range, making it the correct choice. Option A (108/60 mm Hg) is normal blood pressure. Option B (128/88 mm Hg) is prehypertension. Option D (164/104 mm Hg) falls within the stage 2 hypertension range, which is higher than stage 1 hypertension.
A nurse is collecting data from a client who has narcolepsy. Which of the following manifestations should the nurse expect? (Select all that apply).
- A. Feeling extremely tired upon waking
- B. Sudden attacks of sleep
- C. Sleep-wake cycle hallucinations
- D. Sleep apnea
- E. Urge to move the legs when trying to sleep
Correct Answer: B, C
Rationale: The correct manifestations for narcolepsy are sudden attacks of sleep and sleep-wake cycle hallucinations. Narcolepsy is a neurological disorder characterized by excessive daytime sleepiness, sudden attacks of sleep (choice B), and disrupted REM sleep leading to sleep-wake cycle hallucinations (choice C). Choice A (feeling extremely tired upon waking) is more indicative of general fatigue rather than narcolepsy. Choice D (sleep apnea) is a separate sleep disorder characterized by pauses in breathing during sleep. Choice E (urge to move the legs when trying to sleep) is a symptom of restless leg syndrome, which is not typically associated with narcolepsy.