Nokea
A client with a hiatal hernia.
A nursing assessment of a client with a hiatal hernia is MOST likely to reveal
- A. a bulge in the lower right quadrant.
- B. pain at the umbilicus radiating down into the groin.
- C. a burning sensation in the midepigastric area each day before lunch.
- D. complaints of awakening at night with heartburn.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) suggests an inguinal hernia (2) suggests an inguinal hernia (3) pain usually does not develop during the day with an empty stomach (4) correct-classic symptom of hiatal hernia associated with reflux
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The nurse is caring for a client who is postoperative day 1 after a cholecystectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site
- B. Temperature of 100.8°F (38.2°C)
- C. Bile-colored drainage from the T-tube
- D. Urine output of 40 mL/hour
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-cholecystectomy complication. Options A, C, and D are normal: pain is expected, bile drainage is typical, and urine output is adequate.
The nurse is caring for a client with a history of myasthenia gravis.
- A. Which instruction is most important for a client with myasthenia gravis?
- B. Take pyridostigmine on an empty stomach.
- C. Avoid crowds to prevent infections.
- D. Restrict physical activity completely.
- E. Monitor blood pressure daily.
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, critical in myasthenia gravis due to immunosuppressive therapy. Pyridostigmine is taken with food, activity is encouraged, and blood pressure monitoring is not primary.
A client has been receiving chlorpromazine (Thorazine) 400 mg/day for four weeks. He experiences an oral temperature of 105°F (40.5°C), severe rigidity, oculogyric crisis, and severe hypertension. It is MOST important for the nurse to take which of the following actions?
- A. Administer PRN benztropine mesylate (Cogentin) immediately.
- B. Hold the chlorpromazine and notify the medical staff stat.
- C. Place the client in isolation on bedrest in semi-Fowler's position.
- D. Administer acetaminophen 500 mg and place the client on a cooling mattress.
Correct Answer: B
Rationale: Symptoms indicate neuroleptic malignant syndrome, a life-threatening reaction to chlorpromazine. Holding the drug and notifying staff is critical. Options A, C, and D address symptoms but not the cause.
The nurse is caring for a client with a history of chronic pain.
- A. Which intervention is most effective for managing chronic pain?
- B. Administer analgesics as needed only.
- C. Encourage participation in a pain management program.
- D. Restrict physical activity to reduce pain.
- E. Apply ice packs to the painful area.
Correct Answer: B
Rationale: A pain management program (e.g., cognitive-behavioral therapy, physical therapy) addresses chronic pain holistically, improving function and coping. PRN analgesics are less effective long-term, activity is encouraged, and ice is condition-specific.
The nurse knows that the MOST reliable client measure for evaluating the desired response diuretic therapy is to
- A. obtain daily weights.
- B. obtain urinalysis.
- C. monitor Na⺠and K⺠levels.
- D. measure intake.
Correct Answer: A
Rationale: effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights