Nokea
An 88-year-old client fractured a hip after a fall in her home. Because of her peripheral vascular disease and asthma, surgery is not an option. The client tells the nurse she does not know how she is going to get better. Which response by the nurse is best?
- A. You'll do just fine.
- B. You can't live alone anymore.
- C. What are you most worried about?
- D. You should get a second opinion.
Correct Answer: C
Rationale: This response encourages the client to express her concerns, allowing the nurse to address specific fears and provide tailored support.
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The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?
- A. A weight loss of 10 pounds in 2 weeks
- B. Complaints of numbness and tingling in the extremities
- C. A red, beefy tongue
- D. A hemoglobin level of 12.0 gm/dL
Correct Answer: C
Rationale: A red, beefy tongue is a classic sign of pernicious anemia due to vitamin B12 deficiency affecting mucosal tissues.
The body part that would most likely display jaundice in the dark-skinned individual is the:
- A. Conjunctiva of the eye
- B. Soles of the feet
- C. Roof of the mouth
- D. Shins
Correct Answer: A
Rationale: The conjunctiva of the eye is the most reliable site to assess jaundice in dark-skinned individuals, as it is less affected by skin pigmentation.
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: A wound with eschar covering the bed is unstageable because the depth cannot be assessed until the eschar is removed.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Document the finding.
- B. Contact the physician.
- C. Elevate the head of the bed.
- D. Administer a pain medication.
Correct Answer: B
Rationale: The vital signs indicate shock, so contacting the physician for immediate intervention is the priority.
The nurse is working on the cardiac unit with a client scheduled to receive digitalis. The nurse understands that which finding is a contraindication for this medication? Select all that apply.
- A. AV block
- B. atrial flutter
- C. atrial fibrillation
- D. sick sinus syndrome
- E. Wolff-Parkinson-White syndrome
Correct Answer: A,D,E
Rationale: AV block, sick sinus syndrome, and Wolff-Parkinson-White syndrome are contraindications for digitalis due to the risk of worsening conduction abnormalities. Atrial flutter and fibrillation are indications.