Nokea
An African client has been diagnosed with Osteomyelitis. The nurse expects to assess which of the following?
- A. pale, cool, tender skin at site
- B. decreased white blood cell count
- C. positive wound cultures
- D. decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: Osteomyelitis is an infection of the bone often caused by bacteria. When a client is diagnosed with Osteomyelitis, the nurse would expect to assess for positive wound cultures. This means that the wound site is likely to show growth of infectious organisms, confirming the presence of infection in the bone. A positive wound culture result helps guide appropriate antibiotic therapy to treat the infection effectively. Therefore, option C is the most appropriate assessment finding to expect in a client diagnosed with Osteomyelitis.
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When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
- A. Bend forward at the waist with arms hanging freely.
- B. Lie flat on the floor and extend her legs straight from the trunk.
- C. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
- D. Stand against a wall while pressing the length of her back against the wall.
Correct Answer: A
Rationale: When assessing a female adolescent for scoliosis, the nurse should ask the client to bend forward at the waist with arms hanging freely. This Adams forward bend test allows the nurse to evaluate the spine for any asymmetry, curvature, or rib hump that may indicate scoliosis. By observing the alignment of the spine while the client is in a forward bent position, the nurse can gather important information to determine if further evaluation or referral to a healthcare provider is necessary.
The client is a type II DM patient. The client asks the nurse what is the primary reason a type II diabetic does not usually develop diabetic ketoacidosis?
- A. there is no insulin available for the state of hyperglycemia
- B. the type II diabetic has no protein of fat reserves
- C. there is no sufficient insulin to prevent the breakdown of protein and fatty acid for metabolic needs
- D. there is insufficient serum glucose concentrations
Correct Answer: C
Rationale: The primary reason a type II diabetic does not usually develop diabetic ketoacidosis is that there is no sufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs. In type II diabetes, the body still produces some insulin, unlike in type I diabetes where there is a complete lack of insulin. However, the insulin that is produced in type II diabetes may not be enough to effectively lower blood sugar levels and prevent the breakdown of protein and fatty acids for energy. This imbalance can lead to high blood sugar levels, known as hyperglycemia, but not to the extent of causing diabetic ketoacidosis, which typically occurs in the absence of sufficient insulin to prevent the breakdown of fats into ketones.
Which of the following is a discharge criterion from the PACU for a patient following surgery?
- A. Oxygen saturation above 90%
- B. IV narcotics given less than 15 minutes ago
- C. Oxygen saturation below 90%
- D. IV narcotics given less than 30 minutes ago
Correct Answer: A
Rationale: Oxygen saturation above 90% is a discharge criterion from the PACU (Post-Anesthesia Care Unit) for a patient following surgery. This indicates that the patient is effectively exchanging oxygen and carbon dioxide, which is essential for proper respiratory function. Adequate oxygenation is crucial for the patient to be safely discharged from the PACU and transitioned to a regular hospital room or home. Monitoring oxygen saturation helps ensure that the patient's respiratory status is stable before leaving the PACU. If a patient's oxygen saturation is below 90%, further assessment and interventions may be necessary before discharge is considered.
You are examining an infant with multiple cutaneous hemangiomas; you suspect involvement of internal organs. The MOST common site of visceral involvement by hemangiomas is
- A. brain
- B. heart
- C. lung
- D. liver
Correct Answer: D
Rationale: Liver is the most common site of visceral involvement by hemangiomas.
A patient who is recovering from a stroke becomes easily frustrated when unable to complete a task. Which of the ff. responses by the nurse will best help the patient get the task done?
- A. Perform the task for the patient
- B. Tell the patient not to worry about it
- C. Break the task down into simple steps
- D. Have another patient demonstrate how to perform the task
Correct Answer: C
Rationale: Breaking the task down into simple steps is the best response by the nurse to help the patient get the task done. By breaking the task into smaller, more manageable steps, the patient can focus on completing each step successfully, leading to a sense of accomplishment and reducing frustration. This approach promotes a positive and empowering experience for the patient, ultimately aiding in their recovery and rehabilitation process.