Nokea
A nurse is teaching a client about crutch walking. Which of the following instructions should the nurse include?
- A. Bear weight on the axillae
- B. Keep elbows extended while walking
- C. Place crutches 6–10 inches to the side and front
- D. Step with the affected leg first
Correct Answer: C
Rationale: Crutches should be placed 6–10 inches to the side and front for stability. Weight is borne on hands, elbows are flexed, and the unaffected leg steps first.
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An adult client has been admitted to the hospital with a 3-day history of uncontrolled vomiting and diarrhea. Which should the nurse assess for in this client? Select all that apply.
- A. Excitability
- B. Bradycardia
- C. Hypertension
- D. Poor skin turgor
- E. Flat peripheral veins
Correct Answer: D,E
Rationale: The client described in the question will most likely be dehydrated because of uncontrolled vomiting and diarrhea. The nurse assesses this client for weight loss, lethargy, or headache; sunken eyes; poor skin turgor (such as tenting); flat neck and peripheral veins; tachycardia; and low blood pressure.
The charge nurse determines that the new nurse understands the concepts associated with suicide and suicide intentions when the new nurse makes which statement?
- A. Only the psychotic individual commits suicide.
- B. Suicidal attempts are attention-seeking behaviors.
- C. Suicide runs in the family, so there is nothing that health care personnel can do about it.
- D. Many individuals who commit suicide have talked about their suicidal intentions to others.
Correct Answer: D
Rationale: Most people who do commit suicide have given definite clues or warnings about their intentions. The individual who is suicidal is not necessarily psychotic. A suicide attempt is not an attention-seeking behavior, and each act should be taken very seriously. Suicide is not an inherited condition. The remaining options are considered myths regarding suicide.
The nurse is caring for a client who has just undergone a cesarean section. Which of the following interventions is most important in the immediate postoperative period?
- A. Encouraging early ambulation.
- B. Administering oral fluids immediately.
- C. Monitoring for signs of infection.
- D. Applying heat to the incision site.
Correct Answer: A
Rationale: Encouraging early ambulation post-cesarean section prevents complications like deep vein thrombosis and promotes recovery.
A 16-year-old Hispanic client at 10 weeks' gestation has been diagnosed with mild iron deficiency anemia. The client tells the nurse that she doesn't like to eat much meat. Which of the following foods should the nurse suggest to provide the client with the greatest amount of iron in her diet?
- A. 1 cup of lentils
- B. 1 cup of sunflower seeds
- C. 1/2oz of hard cheese
- D. 2 poached eggs
Correct Answer: A
Rationale: Lentils are a rich plant-based source of iron, providing significantly more iron per serving than sunflower seeds, cheese, or eggs, making them ideal for a client avoiding meat.
An adolescent with type 1 diabetes mellitus is hospitalized for appendicitis. He is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client's breath. The client uses insulin. The nurse should suspect:
- A. Diabetic ketoacidosis
- B. Hypoglycemia
- C. Hyperglycemia
- D. Insulin overdose
Correct Answer: A
Rationale: Fruity breath, weakness, nausea, and poor skin turgor in a type 1 diabetic suggest diabetic ketoacidosis, a complication of uncontrolled hyperglycemia. Hypoglycemia would present with shakiness or sweating, not fruity breath.