Nokea
A young adult client involved in a minor motor vehicle collision three weeks ago reports having a headache, blurred vision, vertigo, and nausea. The client's vital signs are within normal limits, and a nutrition history reveals that the client is eating very little because of being concerned about paying for car repairs. Priority nursing care should be based on which nursing problem?
- A. High risk for injury related to increased intracranial pressure.
- B. Alteration in comfort related to motor vehicle collision.
- C. Alteration in nutrition related to poor dietary intake.
- D. Anxiety related to unknown outcome of automobile repairs.
Correct Answer: A
Rationale: Symptoms suggest increased intracranial pressure, a serious post-collision complication, prioritizing over comfort or nutrition.
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The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?
- A. An adolescent who drinks a minimum of four diet drinks daily.
- B. A client who is too busy at work to void when the urge occurs.
- C. A multipara who had pyelonephritis during her last pregnancy.
- D. An older adult who is usually incontinent of urine during the night
Correct Answer: C
Rationale: A history of pyelonephritis increases UTI risk due to prior severe urinary infection, unlike dietary habits or incontinence.
The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?
- A. First voided specimen in the morning.
- B. A clean catch specimen.
- C. Any specimen voided after drinking adequate fluids.
- D. A 24-hour specimen.
Correct Answer: B
Rationale: A clean catch specimen minimizes contamination, providing accurate results for diagnosing urethritis, unlike other methods.
The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?
- A. Weight gain.
- B. Hypoventilation.
- C. Cold intolerance.
- D. Lethargy
Correct Answer: B
Rationale: Hypoventilation can lead to hypoxemia and hypercapnia, requiring immediate intervention to prevent respiratory crisis. Other symptoms are common but not immediately life-threatening.
Nurses' Notes
Assessment is completed. The nurse notes that the nail angle is 180 degrees when viewed from the side and is spongy when palpated.
The nurse reviews client data. Select the 3 possible conditions that could have the clinical manifestation of clubbed nails for this client.
- A. Pneumonia
- B. Lung cancer
- C. Flu
- D. Chronic obstructive pulmonary disease (COPD)
- E. Chronic bronchitis
Correct Answer: B,E
Rationale: Lung cancer and chronic bronchitis are associated with clubbed nails due to chronic hypoxemia, unlike pneumonia or flu.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Client describes a schedule for antacid use with other prescribed medications.
- B. Client selects a pattern of small meals alternating with fluid intake.
- C. Client expresses a willingness to reduce nicotine intake.
- D. Client agrees to participate in a variety of stress reduction techniques.
Correct Answer: B
Rationale: Small, frequent meals reduce rapid gastric emptying, addressing dumping syndrome symptoms post-Billroth II.