Nokea
Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:
- A. hypothalamus.
- B. thalamus.
- C. cortex.
- D. medulla.
Correct Answer: A
Rationale: The hypothalamus, when injured, can cause fluctuations and disruptions in sleep patterns.
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Which of these would be an appropriate meal for a client with Celiac disease?
- A. egg noodles with cream sauce and broccoli, oat cookie, almond milk
- B. turkey sandwich with rye bread, carrots
- C. chicken and rice, apple, and tapioca pudding
- D. granola and dried apricots with cow's milk
Correct Answer: C
Rationale: Rice, fruits, vegetables, meat, dairy, and tapioca are all safe gluten-free options. Oats can be a gluten-free food if they are specially labeled, but many are processed on the same equipment as wheat and so they should not automatically be considered a safe item. Unless marked, granola typically contains oats that could have been exposed to gluten. While fresh fruit is safe, dried and prepackaged fruits may contain additives that contain gluten. Rye is wheat derivative, and many cream sauces contain flour as a base.
The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?
- A. The student should not be touching the plaster cast because it is wet.
- B. The student should be using a pillow to lift the client's casted extremity.
- C. The student is correctly handling a wet plaster cast with the palms.
- D. The student should be using fingers and not the palms to handle the cast.
Correct Answer: C
Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.
A spinal change occurring with pregnancy that alters mobility is:
- A. scoliosis.
- B. kyphosis.
- C. lordosis.
- D. ankylosing spondylitis.
Correct Answer: C
Rationale: The spinal change occurring with pregnancy is lordosis. This occurs due to the weight of the enlarging uterus and the affect of gravity.
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct Answer: D
Rationale: A back rub and warm milk promote relaxation and sleep. Vigorous exercise, cool showers, hot tea, and late TV watching are stimulating and disrupt sleep.
A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
- A. plantar fasciitis.
- B. hallux valgus.
- C. hammertoe.
- D. Morton's neuroma.
Correct Answer: D
Rationale: Morton's neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as a bunion. Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.