Nokea
During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client's knees. The best action for the nurse to take is to
- A. Ask the client for more information about the nature of the bruises
- B. Ask the client and then the family about the findings
- C. Report the bruising to social services to follow-up
Correct Answer: A
Rationale: Cupping' is practiced by Vietnamese. The principle is to create a vacuum inside a special cup by igniting alcohol-soaked cotton inside the cup. When the flame extinguishes, the cup is immediately applied to the skin of the painful site. The belief: the suction exudes the noxious element. The greater the bruise, the greater the seriousness of the illness.
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The nurse is caring for a client with a history of deep vein thrombosis.
- A. Which intervention is most important for a client with a deep vein thrombosis?
- B. Administer analgesics for pain relief.
- C. Apply warm, moist compresses to the leg.
- D. Encourage active range-of-motion exercises.
- E. Maintain bed rest with leg elevation.
Correct Answer: D
Rationale: Bed rest with leg elevation reduces venous pressure and prevents clot dislodgement in DVT. Analgesics and compresses are supportive, and active exercises risk embolization.
A young woman who is at 32 weeks gestation reports to the physician's office for a routine prenatal visit. Which comment by the woman must be reported to the physician?
- A. I had to stop wearing my rings because my fingers are swollen.'
- B. I seem to be hotter than everyone else.'
- C. My feet tend to swell in the hot weather.'
- D. My breasts are so big and tender.'
Correct Answer: A
Rationale: Finger swelling severe enough to prevent wearing rings may indicate preeclampsia, requiring physician evaluation. Heat sensation, foot edema, and breast changes are normal in pregnancy.
An infant with a positive PKU blood Test .
The nurse knows that which of the following plans would be a priority for an infant with a positive PKU blood Test ?
- A. Place the infant on Lofenlac formula.
- B. Administer medium-chain triglyceride (MCT) oil with each feeding.
- C. Provide genetic counseling for the family.
- D. Place the infant on Lorenzo's Oil treatments.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-Guthrie blood Test evaluates neonate for phenylketonuria (PKU); Lofenalac formula is low in phenylalanine, but contains minerals and vitamins to provide a balanced nutritional formula (2) could be a plan for a child with cystic fibrosis (3) important, but is not as high a priority as answer choice #1 (4) would be a plan of care for a child with adrenoleukodystrophy (ALD)
A newly diagnosed diabetic is learning to administer her injections of NPH and regular insulin. Which statement indicates that the client understands the nurse's teaching regarding proper insulin administration?
- A. I will administer the NPH and regular insulin in two separate injections.
- B. I will withdraw the dose of regular insulin before withdrawing the NPH insulin.
- C. It does not matter which insulin is withdrawn first as long as the amount is correct.
- D. I will withdraw the dose of NPH insulin before withdrawing the regular insulin.
Correct Answer: B
Rationale: When mixing NPH and regular insulin, regular insulin (clear) should be withdrawn first to avoid contaminating it with NPH (cloudy). Separate injections are not standard. Order matters (C is incorrect). Withdrawing NPH first risks contamination.
A 5-year old is admitted to the hospital with pneumonia. Her orders include chest physiotherapy, mist tent, and inhalation with Mucomyst (acetylcysteine). Which of the following measures should be included in her care?
- A. Telling her to breathe in through her nose and breathe out through her mouth
- B. Applying lotion to the exposed parts of her body
- C. Checking her clothing and linen frequently for dampness
- D. Obtaining a rectal temperature q 4 hours
Correct Answer: C
Rationale: Checking clothing and linen for dampness is necessary due to the mist tent, which can cause moisture buildup, leading to discomfort or skin issues.