Nokea
During an assessment, a healthcare professional observes significant tenting of the skin over an older adult client's forearm. What factor should the healthcare professional primarily consider as a cause for this finding?
- A. Thin, parchment-like skin
- B. Loss of adipose tissue
- C. Dehydration
- D. Diminished skin elasticity
Correct Answer: C
Rationale: Dehydration is the primary factor to consider in this scenario. Dehydration leads to decreased skin turgor and tenting, where the skin does not return to its normal position when pinched. While thin, parchment-like skin, loss of adipose tissue, and diminished skin elasticity can contribute to skin changes, they are not the primary cause of the significant tenting observed.
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A client is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which complication?
- A. Hypoglycemia
- B. Hyperglycemia
- C. Hypertension
- D. Hyperkalemia
Correct Answer: B
Rationale: Hyperglycemia is the correct complication to monitor for in a client receiving total parenteral nutrition (TPN) due to the high glucose content of the solution. TPN solutions are rich in glucose, so monitoring blood glucose levels is crucial to prevent hyperglycemia. Hypoglycemia (Choice A) is less common with TPN due to the high glucose content, making hyperglycemia a more significant concern. Hypertension (Choice C) and hyperkalemia (Choice D) are not typically associated with TPN administration, making them incorrect choices in this scenario.
A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most appropriate?
- A. Ask the wife how she would like to participate in the client's care
- B. Provide the wife with information about hospice
- C. Encourage the wife to visit during the treatment process
- D. Refer her to a support group for family members of those with terminal cancer
Correct Answer: A
Rationale: In this situation, it is crucial to involve the wife in the care of the client to provide support and empower her. Asking the wife how she would like to participate allows her to be actively involved in decision-making and caregiving. Providing information about hospice (choice B) might be premature as the couple may still be digesting the diagnosis. Encouraging the wife to visit during the treatment process (choice C) may not address her immediate need for involvement and support. Referring her to a support group for family members (choice D) is helpful but involving her directly in the client's care is a more immediate and personalized approach.
The healthcare provider is assessing a client with suspected tuberculosis. Which symptom would be most concerning?
- A. Night sweats
- B. Weight loss
- C. Cough with bloody sputum
- D. Fatigue
Correct Answer: C
Rationale: Cough with bloody sputum is a hallmark symptom of tuberculosis and is highly concerning as it indicates active disease. Hemoptysis (coughing up blood) is associated with tuberculosis infection in the lungs. While night sweats and weight loss are common symptoms of tuberculosis, they are less specific than coughing with bloody sputum. Fatigue is a nonspecific symptom that can be present in various conditions and is not specific to tuberculosis.
A nurse is preparing an education program for staff about advocacy. What information should the nurse include?
- A. Advocacy ensures clients' safety, health, and rights.
- B. Advocacy involves only supporting client complaints.
- C. Advocacy means making all decisions for the client.
- D. Advocacy is not part of nursing responsibilities.
Correct Answer: A
Rationale: The correct answer is A. Advocacy in nursing involves ensuring clients' safety, health, and rights. Nurses advocate for their clients by promoting autonomy, informed decision-making, and protecting their rights. Choice B is incorrect because advocacy goes beyond just supporting client complaints; it encompasses a broader scope of ensuring holistic care and well-being. Choice C is incorrect as advocacy does not mean making all decisions for the client but rather empowering them to make informed choices. Choice D is incorrect as advocacy is a crucial component of nursing responsibilities, as it involves standing up for clients' best interests and ensuring their rights are respected.
A healthcare provider is providing range of motion to the shoulder and must perform external rotation. Which action will the provider take?
- A. Moves the patient's arm in a full circle.
- B. Moves the patient's arm across the body as far as possible.
- C. Moves the patient's arm behind the body, keeping the elbow straight.
- D. Moves the patient's arm until the thumb is upward and lateral to the head with the elbow flexed.
Correct Answer: D
Rationale: The correct action for external rotation of the shoulder involves moving the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position maximizes external rotation at the shoulder joint. Choices A, moving the arm in a full circle, B, moving the arm across the body, and C, moving the arm behind the body with the elbow straight, do not describe external rotation and are incorrect. Therefore, Choice D is the correct action for performing external rotation.