Nokea
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.
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While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
- A. Jaundice evident at 26 hours
- B. Hematocrit of 55%
- C. Serum bilirubin of 12 mg
- D. Positive Coombs' test
Correct Answer: C
Rationale: The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg, the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.
The nurse is assessing a client with suspected rheumatoid arthritis. Which of the following findings would support this diagnosis?
- A. Morning stiffness lasting over 30 minutes.
- B. Heberden’s nodes on the fingers.
- C. Pain in a single joint after exercise.
- D. Fever and weight loss without joint pain.
Correct Answer: A
Rationale: Morning stiffness lasting over 30 minutes is a hallmark of rheumatoid arthritis due to synovial inflammation. Heberden’s nodes (B) indicate osteoarthritis, single-joint pain (C) suggests injury, and fever/weight loss (D) are nonspecific without joint involvement.
An adult had an open cholecystectomy and has an open wound. The client refuses to look at the area during the dressing change. What is the most likely reason for this behavior?
- A. Denial of surgery
- B. Change in body image
- C. The client fears becoming nauseated at the sight of the wound.
- D. The client does not like the sight of blood.
Correct Answer: B
Rationale: Refusing to look at the wound suggests difficulty accepting a change in body image post-cholecystectomy, a common emotional response.
The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is
- A. touching the trapezius muscle or arm firmly
- B. pinching any body part
- C. shaking a limb vigorously
- D. rubbing the sternum
Correct Answer: D
Rationale: rubbing the sternum. The purpose is to assess the non-responsive client's reaction to a painful stimulus after less noxious methods have been tried.
A young female patient comes to the physician because she has been experiencing fatigue and double vision. The physician suspects myasthenia gravis.
When obtaining information from the patient, the nurse would expect her to report that:
- A. Her level of fatigue has been constant.
- B. The longer she rests the weaker she feels.
- C. Her strength increases with progressive activity.
- D. The symptoms seem more severe in the evening.
Correct Answer: D
Rationale: Myasthenia gravis symptoms worsen with activity and are more severe in the evening due to muscle fatigue.