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Assisting with data collection, a nurse notes tenderness while lightly palpating a client's right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?
- A. Liver
- B. Spleen
- C. Pancreas
- D. Appendix
Correct Answer: D
Rationale: The correct answer is the Appendix. Tenderness in the right lower quadrant of the abdomen is a classic sign of appendicitis, which is inflammation of the appendix. The appendix is located in the right lower quadrant. The other choices are incorrect. The spleen is located on the posterolateral wall of the abdominal cavity under the diaphragm. The pancreas is located behind the stomach. The liver fills most of the right upper quadrant and extends to the left midclavicular line.
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A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?
- A. Coffee
- B. A tuning fork
- C. A wisp of cotton
- D. An ophthalmoscope
Correct Answer: C
Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse uses a wisp of cotton to test the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a non-noxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Choice A, 'Coffee,' is incorrect because it is used to present non-noxious aromatic substances to assess cranial nerve I. Choice B, 'A tuning fork,' is used to assess the function of cranial nerve VIII (acoustic nerve). Choice D, 'An ophthalmoscope,' is used to assess the internal structures of the eye, not cranial nerve I.
The LPN is taking care of a client who is on Phenelzine (Nardil) for depression. Which meal would the nurse encourage the client to avoid?
- A. steak and potatoes
- B. prosciutto and cheese plate
- C. orange juice and toast
- D. carbonated water, shrimp and rice
Correct Answer: B
Rationale: The correct answer is 'prosciutto and cheese plate.' Phenelzine (Nardil) is an MAOI (Monoamine Oxidase Inhibitor), and clients on these drugs should avoid foods high in tyramine due to the risk of dangerous elevations in blood pressure. Prosciutto and aged cheeses are examples of foods rich in tyramine, so they should be avoided. Choices A, C, and D do not contain high levels of tyramine and are considered safe to consume while on Phenelzine.
When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is:
- A. Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse.'
- B. Fertility counseling should be sought when you have not been able to conceive after 6-9 months of unprotected intercourse.'
- C. The average time it takes someone your age to conceive is 5-12 months, so if you haven't conceived by then, we can refer you.'
- D. We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn't happen within a year.'
Correct Answer: D
Rationale: The guidelines for a fertility workup are to refer after the couple has not conceived after one year of unprotected intercourse. So, Choice 1 is technically correct, but it doesn't consider the immediate need for the couple to have some counseling. Choice 4 is the best answer because it gives the couple guidance now and the referral at the appropriate time. If the woman is over the age of 35, an earlier referral, at six to nine months of unprotected intercourse, is appropriate. It is true that the average time it takes a 25-year-old woman to conceive is 5.3 months, but that does not address the concern the client is expressing. Choice 4 is still the most caring and correct answer. Couples conceive within the first month of unprotected intercourse 20% of the time.
The client is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?
- A. "I am nervous about how painful labor will be."?
- B. "I need to review my finances and make sure I am prepared to care for a child."?
- C. "I hate this nausea that I've been having for a week."?
- D. "I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent."?
Correct Answer: D
Rationale: The nurse should follow up on the client's lack of a support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea. However, the priority is to address the client's statement about preparing to handle the pregnancy on her own due to the absence of nearby family support. This could have significant implications for the client's emotional well-being and ability to cope effectively throughout the pregnancy journey.
A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?
- A. The client has a fever.
- B. The skin temperature is normal.
- C. The client needs to drink additional fluids.
- D. The client needs to have the blanket removed.
Correct Answer: B
Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.