Nokea
Arterial ulcers are best described as ulcers that:
- A. Are smooth in texture
- B. Have irregular borders
- C. Are cool to touch
- D. Are painful to touch
Correct Answer: D
Rationale: Arterial ulcers caused by poor blood flow are typically painful due to tissue ischemia. They often have irregular borders a pale base and may be cool due to reduced circulation but pain is the most defining feature.
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A client with a history of stroke is admitted with complaints of hemiparesis. The nurse should give priority to:
- A. Providing physical therapy
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering anticoagulants
Correct Answer: A
Rationale: Physical therapy improves strength and mobility in hemiparesis post-stroke, promoting recovery.
Which complaint is frequently expressed by a client with macular degeneration?
- A. Problems with activities requiring focused vision such as sewing
- B. Severe eye and face pain accompanied by nausea and vomiting
- C. Seeing halos around lights
- D. Veil-like loss of vision
Correct Answer: A
Rationale: Macular degeneration affects central vision, impairing activities like sewing or reading that require focused vision. Severe pain with nausea is typical of acute glaucoma, halos suggest cataracts or glaucoma, and veil-like vision loss is more associated with retinal detachment.
A five-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of:
- A. Scarf sign
- B. Harlequin sign
- C. Cullen's sign
- D. Trendelenburg sign
Correct Answer: D
Rationale: Trendelenburg sign, where the pelvis tilts downward on the unaffected side when standing on the affected leg, is associated with congenital hip dysplasia due to weak hip abductors. The other signs are unrelated.
Which of the following is an expected finding in a child with osteogenesis imperfecta?
- A. Blue sclera
- B. Hutchinson's teeth
- C. Anisocoria
- D. Pectus excavatum
Correct Answer: A
Rationale: Blue sclera is a hallmark of osteogenesis imperfecta due to thin connective tissue in the eyes. Hutchinson’s teeth are associated with congenital syphilis anisocoria is unequal pupil size and pectus excavatum is a chest deformity not specific to this condition.
A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:
- A. Raise the client's head and place her feet in a dependent position
- B. Notify the physician
- C. Place the client on 2 liters of O2 via nasal cannula
- D. Administer furosemide (Lasix) 20 mg IV push
Correct Answer: A
Rationale: Raising the head and placing feet in a dependent position reduces venous return and pulmonary congestion, addressing transfusion-related circulatory overload.