Nokea
Additional assessment on Antoinette include
dehydration and menorrhagia.
- A. buffalo hump and hypertension.
- B. pitting edema and frequent colds.
- C. migraine headache and dymennorhea.
Correct Answer: B
Rationale: Cushing's syndrome results from excess adrenocortical activity. Signs include slow wound healing, buffalo hump, hirsutism, weight gain, hypertension, acne, moon face, thin arms and legs, and behavioral changes.
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Which interventions are appropriate when caring for a client with acute thrombophlebitis?
- A. Apply cool soaks and keep the client's leg lower than the level of the heart
- B. Increase the client's activity level and encourage leg exercises
- C. Apply cool soaks and administer nitroglycerin
- D. Apply warm soaks and elevate the client's legs higher than the level of the heart
Correct Answer: D
Rationale: To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time.
A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?
- A. Head of bed elevated 30°-45°.
- B. Head of bed elevated 60°-90°.
- C. Side-lying with head elevated 15°.
- D. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: Positioning the patient with the head of the bed elevated 60°-90° (high Fowler’s position) facilitates swallowing and allows gravity to aid the passage of the nasogastric (NG) tube through the esophagus into the stomach. This position reduces the risk of aspiration and eases tube insertion. Lower elevations (30°-45°), side-lying, or flat positions do not optimize swallowing or tube advancement as effectively.
During a home visit, the nurse observes a man who is recovering from a left total hip replacement. Which observation indicates that the client understands his care?
- A. He is sitting in a soft, overstuffed easy chair.
- B. He bends over to pat his cat.
- C. He crosses his legs when sitting.
- D. He holds the cane in his right hand when walking.
Correct Answer: D
Rationale: Holding the cane in the right hand (opposite the affected left hip) provides support and balance, indicating proper care understanding. Soft chairs, bending, or crossing legs risk hip dislocation.
The nurse is caring for a client who had knee surgery this morning. Postoperative orders include a narcotic every three to four hours as needed for operative site pain and an ice bag. At 7:00 P.M., the client asks for pain medication. He was last medicated at 3:30 P.M. What is the best initial nursing action?
- A. Administer the prescribed analgesic
- B. Assess the location and nature of the pain
- C. Refill the ice bag as needed
- D. Reposition the client
Correct Answer: B
Rationale: Assessing pain location and nature ensures the medication is appropriate for operative site pain, guiding safe administration. Administering without assessment, refilling ice, or repositioning are premature.
Which of the following is the primary force in sex education in a child's life?
- A. school nurse
- B. peers
- C. parents
- D. media
Correct Answer: C
Rationale: Parents are the primary influence on a child's sex education, providing foundational values and information. Other sources like peers and media are influential but secondary. Health Promotion and Maintenance