Nokea
After a laminectomy, the client states, 'The physician said that I can do anything I want to.' Which of the following client-stated activities indicates the need for further teaching?
- A. Drying the dishes.
- B. Sitting outside on firm cushions.
- C. Making the bed walking from side to side.
- D. Sweeping the front porch.
Correct Answer: D
Rationale: Sweeping involves twisting and bending, which can strain the surgical site post-laminectomy.
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A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss?
- A. Hypotension.
- B. Decreased serum potassium level.
- C. Rapid, deep respirations.
- D. Warm, dry skin.
Correct Answer: C
Rationale: Rapid, deep respirations (Kussmaul respirations) in diabetic ketoacidosis are a compensatory mechanism for acidosis, leading to significant fluid loss through hyperventilation.
A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation?
- A. Tell the client firmly that she needs assistance and help her with her care.
- B. Praise the client for her desire to be independent and give her extra time and encouragement.
- C. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help.
- D. Suggest to the client that if she insists on self-care, she should at least modify her routine.
Correct Answer: B
Rationale: Praising independence and providing extra time respects the client's autonomy while supporting her efforts. Forcing help, labeling her unrealistic, or suggesting modifications may undermine her dignity.
When performing postural drainage, which of the following factors promotes the movement of secretions from the lower to the upper respiratory tract?
- A. Friction between the cilia.
- B. E. Force of gravity.
- C. Sweeping motion of cilia.
- D. Involuntary muscle contractions.
Correct Answer: B
Rationale: The force of gravity in postural drainage positions the body to allow secretions to drain from lower to upper airways. Cilia and muscle contractions aid clearance but are not the primary mechanism.
A common abnormal laboratory result associated with the development of peripheral vascular disease (PVD) is:
- A. High serum calcium level
- B. High serum lipid levels
- C. Low serum lipid levels
- D. Low serum calcium level
Correct Answer: B
Rationale: High serum lipid levels, particularly elevated low-density lipoprotein (LDL) cholesterol, are a major risk factor for atherosclerosis, which underlies PVD. Lipid accumulation in arterial walls leads to plaque formation, narrowing vessels and reducing blood flow. Calcium levels are not directly associated with PVD, and low lipid levels are not a risk factor.
A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply.
- A. Sympathetic nervous system activation.
- B. Renin-angiotensin-aldosterone system activation.
- C. Myocardial hypertrophy.
- D. Natriuretic peptide release.
- E. Ventricular dilation.
Correct Answer: A,B,C,D,E
Rationale: Heart failure activates the sympathetic nervous system (A), renin-angiotensin-aldosterone system (B), myocardial hypertrophy (C), natriuretic peptide release (D), and ventricular dilation (E) to compensate for reduced cardiac output.