Nokea
A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?
- A. Left upper quadrant
- B. Left lower quadrant
- C. Right upper quadrant
- D. Right lower quadrant
Correct Answer: D
Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there. Then, the nurse proceeds to listen for bowel sounds in the other quadrants. Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.
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While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?
- A. Document the finding
- B. Palpate the area for a mass
- C. Notify the healthcare provider
- D. Percuss the abdomen to check for tympany
Correct Answer: C
Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.
During data collection of a client with suspected carpal tunnel syndrome, a nurse plans to perform the Phalen test. The nurse should ask the client to perform which activity?
- A. Dorsiflex the foot
- B. Plantarflex the foot
- C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds
- D. Hyperextend the fingers with the palmar surfaces of the hands touching, holding the position for 60 seconds
Correct Answer: C
Rationale: In the Phalen test, the nurse asks the client to hold the hands back to back while flexing the wrists 90 degrees. This position puts pressure on the median nerve, eliciting symptoms in carpal tunnel syndrome. Dorsiflexing or plantarflexing the foot and hyperextending the fingers are not associated with testing for carpal tunnel syndrome. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand.
Which of these is not a symptom of Serotonin Syndrome?
- A. edema
- B. fever
- C. confusion
- D. tremors
Correct Answer: A
Rationale: Serotonin syndrome, caused by an excess of serotonin, typically presents with symptoms such as altered mental status (confusion), neuromuscular abnormalities (tremors), and autonomic dysfunction (fever). Edema, which refers to swelling caused by fluid retention in the body tissues, is not a common symptom associated with serotonin syndrome. Therefore, the correct answer is 'edema.'
Choice A, 'edema,' is the correct answer as it is not typically seen in serotonin syndrome. Choice B, 'fever,' is a symptom of serotonin syndrome, as it can cause autonomic dysfunction. Choice C, 'confusion,' is a common symptom due to altered mental status in serotonin syndrome. Choice D, 'tremors,' is also a common symptom due to neuromuscular abnormalities in serotonin syndrome.
A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?
- A. Immunizations may be started at any age.
- B. The recommended immunization schedule should be followed.
- C. If a primary series of immunizations is interrupted, it can be continued.
- D. Delaying the start of vaccines does not increase the risk of reaction.
Correct Answer: A
Rationale: The correct answer is 'Immunizations may be started at any age.' While there is a recommended immunization schedule, immunizations can be initiated at any age. It is essential to emphasize the flexibility in starting immunizations. The statement 'The recommended immunization schedule should be followed' is too rigid; while recommended, there is flexibility in initiation. Choice C is correct as an interrupted series can be continued without restarting. The statement 'Delaying the start of vaccines does not increase the risk of reaction' is correct. Delaying does not increase the risk of reaction; in fact, it is important to start immunizations to protect the child and the community.
A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?
- A. Constriction of the underlying blood vessels
- B. An increased amount of bilirubin in the blood
- C. Increased perfusion of the surrounding tissues
- D. Excess blood in the dilated superficial capillaries
Correct Answer: D
Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.