Nokea
An adult is admitted to the emergency department following a fall. A piece of bone is protruding through the skin of the left thigh. In addition to assessing vital signs, what information is most essential to obtain from the client at this time?
- A. History of previous falls and fractures
- B. Date of last tetanus shot
- C. Type of environment where the fall took place
- D. Any previous surgeries
Correct Answer: B
Rationale: An open fracture (bone protruding) risks tetanus infection; knowing the last tetanus shot date is critical to determine prophylaxis need. Fall history, environment, or surgeries are secondary.
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A nurse is reinforcing teaching to the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching?
- A. My child may experience incontinence.'
- B. My child may seem confused afterwards.'
- C. My child may stare and seem inattentive.'
- D. My child will notice unusual odors prior to the event.'
Correct Answer: C
Rationale: Staring and inattention (C) are hallmark signs of absence seizures. Incontinence (A) and confusion (B) are more typical of other seizures, and odors (D) suggest an aura, not typical in absence seizures.
The nurse is collecting data from a client during the first routine prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. The nurse would expect to palpate the uterine fundus
- A. 12 cm above the umbilicus
- B. at the level of the umbilicus
- C. just below the xiphoid process
- D. just above the symphysis pubis
Correct Answer: D
Rationale: At 12 weeks, the uterine fundus is just above the symphysis pubis (D). It reaches the umbilicus at 20 weeks and higher levels later in pregnancy.
Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent feelings?
- A. Direct confrontation
- B. Reality orientation
- C. Projective identification
- D. Active listening
Correct Answer: D
Rationale: Active listening. This skill, along with silence, encourages the client to verbalize feelings.
The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse reinforce with the caregivers before they leave the clinic?
- A. Call the office if the toddler's temperature is higher than 100 F (37.7 C)
- B. Fussiness and anorexia are common for 1 week after immunizations
- C. Redness at the injection sites and a mild fever are common
- D. The toddler's activity level should be restricted for 24 hours
Correct Answer: C
Rationale: Redness and mild fever (C) are common post-immunization reactions. A temperature above 100 F (A) is too low a threshold for concern, fussiness for a week (B) is excessive, and activity restriction (D) is unnecessary.
A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply.
- A. Administer docusate sodium orally every day
- B. Assist in applying an abdominal binder
- C. Implement caloric restriction to promote weight loss
- D. Monitor blood glucose to maintain tight control
- E. Reinforce teaching to hug a pillow while coughing
Correct Answer: B, D, E
Rationale: Abdominal binder (B), glucose control (D), and pillow hugging (E) reduce wound stress and promote healing. Docusate (A) prevents constipation but not dehiscence, and caloric restriction (C) is inappropriate post-surgery.