Nokea
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
- A. I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.'
- B. I rest in my recliner with my feet elevated for about an hour every afternoon.'
- C. I use my heating pad on a low setting to keep my feet warm.'
- D. I soak my feet in hot water before trimming my toenails.'
Correct Answer: A
Rationale: The correct answer is A because applying a lubricating lotion to the cracked areas on the soles of the feet helps prevent further skin breakdown and infection, which is crucial in peripheral arterial disease. Choice B may improve circulation, but it does not address foot care directly. Choice C can lead to burns or injury due to decreased sensation in peripheral arterial disease. Choice D poses a risk of injury or infection due to the potential for skin damage while soaking the feet. Overall, choice A is the most appropriate for maintaining foot health in peripheral arterial disease.
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A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, causing blood to back up into the systemic circulation. This leads to fluid retention, particularly in the lower extremities and abdomen, resulting in increased abdominal girth. Crackles in the lungs (A) are indicative of left-sided heart failure due to pulmonary congestion. Pink frothy sputum (C) is associated with pulmonary edema, a sign of left-sided heart failure. Hypertension (D) is not typically associated with right-sided heart failure, as it is more commonly seen in conditions like systemic hypertension.
A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?
- A. Suppressed bronchiolar inflammatory response
- B. Decreased responsiveness of airways to allergens
- C. Acute loss of alveolar elasticity
- D. Inability to exhale retained carbon dioxide
Correct Answer: D
Rationale: The correct answer is D: Inability to exhale retained carbon dioxide. During an acute asthma attack, there is airway obstruction, leading to air trapping and difficulty exhaling. This causes retention of carbon dioxide, leading to respiratory acidosis. This acidosis can further worsen the bronchoconstriction and airway inflammation in asthma. Choices A, B, and C do not directly contribute to the manifestations of an acute asthma attack. Suppressed bronchiolar inflammatory response (A) and decreased responsiveness of airways to allergens (B) would not cause the acute symptoms seen in an asthma attack. Acute loss of alveolar elasticity (C) is not a primary contributing factor to the acute manifestations of asthma.
A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?
- A. Wound tissue firm to palpation
- B. Dry brown eschar
- C. Light yellow exudate
- D. Dark red granulation tissue
Correct Answer: D
Rationale: The correct answer is D: Dark red granulation tissue. Granulation tissue is a sign of healing in a wound, indicating new blood vessels and collagen formation. Dark red color indicates good blood supply. A: Firm wound tissue can indicate infection or inadequate healing. B: Dry brown eschar is a sign of necrotic tissue, not healing. C: Light yellow exudate can indicate infection or inflammation.
A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?
- A. Edema at the site
- B. Severe pain at the site
- C. Epithelialization at the site
- D. Blistering at the site
Correct Answer: A
Rationale: The correct answer is A: Edema at the site. After sustaining major full-thickness burns, the body initiates an inflammatory response, leading to increased capillary permeability and fluid accumulation in the interstitial space, causing edema. This is a normal physiological response to burns. Edema helps in the healing process by providing nutrients and oxygen to the damaged tissues. Choices B, C, and D are incorrect. Severe pain may not be present initially due to nerve damage from the burn. Epithelialization typically occurs during the later stages of burn healing. Blistering is more commonly seen in partial-thickness burns rather than full-thickness burns.
A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect?
- A. Photophobia
- B. Bradycardia
- C. Intermittent headache
- D. Petechiae on the chest
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Photophobia, or sensitivity to light, is a common symptom of meningitis due to inflammation of the meninges surrounding the brain and spinal cord. This occurs because bright light can worsen the headache associated with meningitis. Bradycardia and petechiae on the chest are not typical findings in meningitis. Intermittent headache is vague and not specific to meningitis.