Nokea
An adult woman who broke her right ankle is seen in the physician's office one week after the cast was applied. Which observation indicates to the office nurse that the client is using crutches correctly?
- A. The client moves the left crutch forward, then the right foot, then the right crutch, and finally the left foot.
- B. The client moves the left crutch and the right foot together, and then moves the right crutch and the left foot together.
- C. The client moves the left foot and the crutches forward while bearing weight on the right foot.
- D. The client bears weight on the left foot, and then moves the right foot and the crutches forward.
Correct Answer: A
Rationale: The four-point crutch gait (left crutch, right foot, right crutch, left foot) is stable and correct for a non-weight-bearing right ankle, ensuring balance and safety.
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Which of these clients would be most appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection
- B. A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia
- C. A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation
- D. A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure
Correct Answer: C
Rationale: This client requires supportive care and interventions within the scope of practice of a PN. This client is stable with little risk of complications or instability.
The nurse is reinforcing discharge teaching for the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply.
- A. Dress the infant in warm clothing and blankets
- B. Encourage smaller, frequent feedings
- C. Intervene quickly to prevent the infant from crying excessively
- D. Promote a quiet period on waking in the morning
- E. Turn the infant frequently during sleep
Correct Answer: B,C,D
Rationale: Smaller feedings, preventing crying, and quiet periods reduce oxygen demand, minimizing hypercyanotic spells. Warm clothing and frequent turning do not directly prevent spells.
While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first?
- A. First-trimester client who reports frequent nausea and vomiting
- B. Second-trimester client with dysuria and urinary frequency
- C. Second-trimester client with obesity who reports decrease in fetal movement
- D. Third-trimester client with right upper quadrant pain and nausea
Correct Answer: C
Rationale: Decreased fetal movement in the second trimester suggests potential fetal distress, requiring urgent evaluation. Nausea, UTI symptoms, and third-trimester pain are concerning but less immediately critical.
A client comes into the community health center upset and crying stating 'I will die of cancer now that I have this disease.' And then the client hands the nurse a paper with one word written on it: 'Pheochromocytoma.' Which response should the nurse state initially?
- A. Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other parts of the body.
- B. This tumor can be treated effectively with chemotherapy.
- C. Surgery is always required to remove this type of tumor.
- D. This condition is always fatal within a few months.
Correct Answer: A
Rationale: Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other parts of the body, providing reassurance and accurate information to alleviate the client's fear.
A client who has Mycoplasma pneumonia needs to go to the radiology department for a chest x-ray. What should the client wear?
- A. A face shield
- B. A surgical mask
- C. An N95 respirator
- D. Gloves and a gown
Correct Answer: B
Rationale: A surgical mask prevents droplet transmission of Mycoplasma pneumonia during transport, protecting others.