Nokea
An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?
- A. Auscultate for presence of bowel sounds.
- B. Monitor hemoglobin and hematocrit
- C. Encourage turning and deep breathing
- D. Administer IV antibiotics as prescribed.
Correct Answer: D
Rationale: Administering IV antibiotics promptly is critical to treat the infection and prevent complications in acute pyelonephritis.
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An older client is admitted after falling while walking. The left leg is externally rotated and shorter than the right leg, and the client is having severe pain and tingling in the left foot. The nurse is unable to palpate the left pedal pulses. Which action is most important for the nurse to implement?
- A. Use a doppler to assess bilateral pedal pulses
- B. Administer pain medication to relieve discomfort.
- C. Position the client’s left leg in a neutral position to reduce pain.
- D. Immobilize the left leg to prevent further injury.
Correct Answer: A
Rationale: Assessing pedal pulses with a doppler is critical to evaluate circulation and detect potential vascular compromise in the affected limb.
Psychosis in children is suggested by:
- A. Absence of speech
- B. Intense outbursts of temper
- C. Recurrence of bed-wetting following a period of control
- D. Feelings of depersonalisation
Correct Answer: D
Rationale: Feelings of depersonalisation are a hallmark of psychosis. Absence of speech and temper outbursts are nonspecific, and bed-wetting is not diagnostic.
Routine hearing tests in the community are usually based on:
- A. Distraction testing
- B. Auditory brainstem responses
- C. Evoked potentials
- D. Object discrimination
Correct Answer: A
Rationale: Distraction testing is a common method used in community settings to assess hearing in young children.
Which food is most important for the nurse to encourage a male client with osteomalacia to include in his daily diet?
- A. Fortified milk and cereals
- B. Lean red meat and poultry
- C. Fresh fruits and vegetables
- D. Whole grains and legumes
Correct Answer: A
Rationale: Fortified foods rich in vitamin D and calcium are crucial for the client with osteomalacia to help in bone mineralization.
The nurse is assessing a client who has tinea pedis. Which question will allow the nurse to gather further information about this condition?
- A. Do you see any improvement when using tolnaftate?
- B. Have you been avoiding wearing tight-fitting shoes?
- C. Are you experiencing pain or itching in your feet?
- D. How often do you wash your feet and change socks?
Correct Answer: A
Rationale: Tolnaftate is an antifungal medication. Asking about its effectiveness helps assess the client's treatment response and adherence.