Nokea
A nurse on an orthopedic unit is caring for four clients with a casted extremity. Which client does the nurse prioritize to see first?
- A. Client reporting a tingling sensation
- B. Client reporting itching under the cast
- C. Client reporting pain of 5/10 on movement
- D. Client reporting throbbing on dependent positioning
Correct Answer: A
Rationale: Tingling (A) suggests neurovascular compromise, requiring urgent assessment. Itching (B), moderate pain (C), and throbbing (D) are less critical.
You may also like to solve these questions
An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP returns to assist the client with a shower, the client curses at and tries to hit the UAP. Which is the most appropriate response by the practical nurse?
- A. I will walk to the room to observe the client's behavior.
- B. It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable.
- C. Just leave the client alone now and try again later.
- D. The client probably has dementia and is under a lot of stress with the change of environment.
Correct Answer: A
Rationale: Observing the client (A) allows assessment of the behavior's cause. Assuming dissatisfaction (B) or dementia (D) is premature. Leaving the client (C) delays intervention.
A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
- A. the muscles
- B. the cerebellum
- C. the kidneys
- D. the leg bones
Correct Answer: A
Rationale: the muscles. Rhabdomyosarcoma is the most common children's soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word -- 'myo' --which typically means muscle.
An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
- A. Have you had a recent heart attack?
- B. Do you become short of breath during your normal daily activities?
- C. How many pillows do you use at night to sleep comfortably?
- D. Do you smoke?
Correct Answer: B
Rationale: Do you become short of breath during your normal daily activities? This assesses for activity intolerance, a symptom of right-sided heart failure causing edema.
A nurse is assigned to a client who is newly admitted for treatment of a frontal lobe brain tumor. Which history offered by the family members would be recognized by the nurse as associated with the diagnosis, and communicated to the provider?
- A. My partner's breathing rate is usually below 12.
- B. I find the mood swings and the change from a calm person to being angry all the time hard to deal with.
- C. It seems our sex life is nonexistent over the past 6 months.
- D. In the morning and evening I hear complaints that reading is next to impossible from blurred print.
Correct Answer: B
Rationale: I find the mood swings and the change from a calm person to being angry all the time hard to deal with. Frontal lobe tumors affect emotions and judgment, causing mood swings and personality changes.
The nurse is caring for a client with acute pancreatitis. While obtaining the client's blood pressure, the nurse notes a carpal spasm. The nurse should obtain a blood specimen to check the client's serum
- A. calcium level
- B. albumin level
- C. troponin T level
- D. potassium level
Correct Answer: A
Rationale: Carpal spasm (Trousseau's sign) suggests hypocalcemia (A), common in pancreatitis. Albumin (B), troponin (C), and potassium (D) are unrelated to this finding.