Nokea
A Stage II pressure ulcer is characterized by:
- A. Redness in the involved area.
- B. Muscle spasms in the involved area.
- C. Pain in the involved area.
- D. Tissue necrosis in the involved area.
Correct Answer: C
Rationale: Stage II pressure ulcers cause pain due to partial-thickness skin loss and exposed nerve endings. Redness is Stage I, and necrosis is Stage III or IV.
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Which of the following diets would be most appropriate in the chronic obstructive pulmonary disease (COPD)?
- A. Low-fat, low-cholesterol diet.
- B. Bland, soft diet.
- C. Low-sodium diet.
- D. High-calorie, high-protein diet.
Correct Answer: D
Rationale: A high-calorie, high-protein diet supports nutritional needs in COPD, where energy expenditure is high and appetite may be low. Other diets are less specific to COPD requirements.
A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/minute and shallow. The nurse interprets these findings as indicating which of the following?
- A. Expected common adverse effects.
- B. Hypersensitivity reaction.
- C. Possible habituating effect.
- D. Hemorrhage from gastrointestinal irritation.
Correct Answer: B
Rationale: These vital signs suggest a hypersensitivity reaction, a serious adverse effect of carisoprodol.
A client with an ileal conduit reports a bulging stoma. The nurse suspects:
- A. Stoma retraction.
- B. Parastomal hernia.
- C. Stoma ischemia.
- D. Infection.
Correct Answer: B
Rationale: A bulging stoma suggests a parastomal hernia, a complication requiring evaluation.
Which of the following changes are associated with normal aging?
- A. The outer layer of skin is replaced with new cells every 3 days.
- B. Subcutaneous fat and extracellular water decrease.
- C. The dermis becomes highly vascular and assists in the regulation of body temperature.
- D. Collagen becomes elastic and strong.
Correct Answer: B
Rationale: Aging reduces subcutaneous fat and extracellular water, leading to thinner, drier skin. Cell replacement slows, vascularity decreases, and collagen loses elasticity.
A nurse is teaching a client about cystoscopy preparation. What instruction should be included?
- A. Fast for 8 hours before the procedure.
- B. Drink plenty of water before the test.
- C. Expect to stay overnight in the hospital.
- D. Empty the bladder before the procedure.
Correct Answer: D
Rationale: Emptying the bladder ensures a clear view during cystoscopy and reduces discomfort.