Nokea
An 85-year-old client with diverticulitis has been vomiting and febrile for 12 hours. Where is the best location to assess skin turgor on this client?
- A. Dorsal hand
- B. Feet
- C. Back of the arm
- D. Sternum
Correct Answer: D
Rationale: This is the best area to check in the elderly due to loss of skin elasticity that occurs with aging. Answers A, B, and C are all influenced by loss of elasticity more than the sternum, so they are incorrect.
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A mother brings her two-year-old boy to the pediatrician’s office.
- A. Which symptom would suggest to the nurse that a two-year-old boy has strabismus?
- B. When the child draws, he places his head close to the table.
- C. The child rubs his eyes frequently.
- D. The child closes one eye to see a poster on the wall.
- E. The child is unable to see objects in the periphery of his visual field.
Correct Answer: C
Rationale: Strabismus is characterized by misaligned visual axes, causing the brain to receive two images. Closing one eye to focus on an object, such as a poster, is a compensatory behavior indicative of strabismus. The other symptoms suggest refractive errors or other visual impairments, not strabismus.
The nurse checks for placement of a nasogastric (NG) tube before beginning a tube feeding for a client.
Which of the following results would indicate to the nurse that the tube feeding can begin?
- A. A small amount of white mucus is aspirated from the NG tube.
- B. The pH of the contents removed from the NG tube is 3.
- C. No bubbles are seen when the nurse inverts the NG tube in water.
- D. The client says he can feel the NG tube in the back of his throat.
Correct Answer: B
Rationale: Strategy: Determine how the answers relate to a tube feeding. (1) mucus may be from lungs (2) correct-stomach contents are acidic (3) not a safe way to check placement (4) not a reliable indication
The nurse is caring for a client with a history of chronic venous insufficiency.
- A. Which intervention is most effective for a client with chronic venous insufficiency?
- B. Apply compression stockings.
- C. Encourage bed rest.
- D. Administer diuretics.
- E. Elevate the head of the bed.
Correct Answer: A
Rationale: Compression stockings improve venous return, reducing edema and stasis in chronic venous insufficiency. Bed rest is discouraged, diuretics are not primary, and head elevation is irrelevant.
Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
- A. Liver function
- B. Kidney function
- C. Blood sugar
- D. Cardiac enzymes
Correct Answer: A
Rationale: Liver function. INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.
The nurse is caring for a client with a history of rheumatoid arthritis.
- A. Which symptom is expected in a client with rheumatoid arthritis?
- B. Morning stiffness lasting over 30 minutes.
- C. Pain that worsens with activity.
- D. Asymmetrical joint involvement.
- E. Rapid onset of symptoms.
Correct Answer: A
Rationale: Morning stiffness lasting over 30 minutes is a hallmark of rheumatoid arthritis due to joint inflammation. Pain improves with activity, joints are symmetrically affected, and onset is gradual.