Nokea
An elderly adult has been admitted with a diagnosis of hypertension with a history of dementia. Which of the following nursing diagnoses has the highest priority for this client?
- A. ineffective coping
- B. activity intolerance
- C. ineffective tissue perfusion
- D. risk for injury
Correct Answer: D
Rationale: Dementia increases fall and injury risk due to impaired judgment and memory, making 'risk for injury' the priority.
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The best size cathlon for administration of a blood transfusion to a six year old is:
- A. 18 gauge
- B. 19 gauge
- C. 22 gauge
- D. 20 gauge
Correct Answer: D
Rationale: A 20-gauge catheter is appropriate for blood transfusion in a six-year-old, balancing flow rate and vessel size.
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial infarction, reflecting cardiac ischemia. Anaphylactic shock typically involves allergic symptoms like urticaria or bronchospasm. Low BP, anxiety, and normal temperature are nonspecific.
The nursing assistant finds a client on the floor. Once the client is safe, which of the following should the nurse do next?
- A. document the event in the client's medical record only
- B. document the event in the client's medical record and file an incident report
- C. document the event in the client's medical record and have the nursing assistant file an incident report
- D. have the nursing assistant file an incident report
Correct Answer: B
Rationale: Falls require documentation in the medical record and an incident report to track safety issues and ensure follow-up.
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
- A. Right breech presentation
- B. Right occipital anterior presentation
- C. Left sacral anterior presentation
- D. Left occipital transverse presentation
Correct Answer: A
Rationale: Fetal heart tones loudest in the upper-right quadrant suggest a breech presentation, with the fetus's heart higher in the uterus.
The nurse is caring for a Muslim client who is recovering from an automobile accident and is unable to cleanse herself after a bowel movement. Which of the following should the nurse do to show respect for the woman's cultural and religious beliefs?
- A. Use the left hand to cleanse the client's rectal area.
- B. Ask a female family member to assist the client.
- C. Wear gloves when cleansing the client's rectal area.
- D. Ask the client's husband to assist the client.
Correct Answer: B
Rationale: In Islamic culture, hygiene after defecation is important, and female clients may prefer assistance from female family members (B) to maintain modesty. The left hand (A) is traditionally used by the client, not the nurse. Gloves (C) are standard but not cultural. The husband (D) may not be appropriate due to modesty.