Nokea
After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which of the following, if stated by the client, would indicate the need for additional teaching?
- A. Pushing with palms when rising from a chair.
- B. Holding packages close to the body.
- C. Sliding objects.
- D. Carrying a laundry basket with clinched fingers and fists.
Correct Answer: D
Rationale: Carrying heavy loads with clinched fingers stresses small joints, increasing pain and deformity risk. The other actions minimize joint strain.
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Which of the following lab values should the nurse report to the health care provider when the client has anemia?
- A. Schilling test result, elevated.
- B. Intrinsic factor, absent.
- C. Sedimentation rate, 16 mm per hour.
- D. Red blood cells (RBCs) within normal range.
Correct Answer: B
Rationale: An absent intrinsic factor is a critical finding in clients with anemia, as it indicates pernicious anemia, a condition where the body cannot absorb vitamin B12 due to a lack of intrinsic factor. This requires immediate medical attention and lifelong B12 supplementation. An elevated Schilling test is not a standard result (the test measures B12 absorption), a sedimentation rate of 16 mm/hour is normal, and normal RBCs do not explain anemia.
A 56-year-old cancer survivor feels guilty at the 'I Can Cope' meetings. The nurse can help him manage his feelings of guilt by pointing out that:
- A. He is really angry at the terminally ill clients in the group.
- B. He is experiencing very volatile emotions.
- C. This is a spiritual response to his illness.
- D. This is a normal reaction when surviving a life-threatening experience.
Correct Answer: D
Rationale: Survivor guilt is a normal reaction for cancer survivors, especially in support groups, and acknowledging this helps the client process their emotions.
Appropriate nursing diagnoses for a client with hypothyroidism would include which of the following?
- A. Risk for injury (corneal abrasion) related to incomplete closure of the eyelid.
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolism.
- C. A clinical evidence related to diarrhea.
- D. Activity intolerance related to fatigue associated with the disorder.
Correct Answer: D
Rationale: Hypothyroidism causes fatigue due to slowed metabolism, making activity intolerance a relevant nursing diagnosis. The other options are more associated with hyperthyroidism or unrelated conditions.
The client has midcalf pain when walking a block or more. The client states that the discomfort is relieved with rest. The pain is expected when arterial occlusion reaches which of the following percentages?
- A. 20%
- B. 40%
- C. 50%
- D. 100%
Correct Answer: C
Rationale: Claudication typically occurs when arterial occlusion reaches approximately 50%, significantly reducing blood flow to muscles during activity. This causes ischemia and pain, which is relieved by rest when oxygen demand decreases. Complete (100%) occlusion would cause rest pain or tissue necrosis, not just claudication.
After the administration of t-PA, the assessment priority is to:
- A. Monitor the client for chest pain.
- B. Monitor for fever.
- C. Monitor the 12-lead electrocardiogram (ECG) every 4 hours.
- D. Monitor breath sounds.
Correct Answer: A
Rationale: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.