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For a client presenting with numbness and pain radiating down the left leg, what further data should the nurse assess?
- A. Posture and gait
- B. Bending and stooping
- C. Leg lifts and arm swing
- D. Waist twists and neck mobility
Correct Answer: A
Rationale: Assessing posture and gait can help identify abnormalities related to nerve compression.
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The nurse suspects that a patient is experiencing a recurrent herpes simplex virus infection. Which assessment finding is most characteristic of this condition?
- A. Fever
- B. Anorexia
- C. Areas of redness
- D. Fluid-filled vesicles
Correct Answer: D
Rationale: Fluid-filled vesicles are the hallmark of recurrent herpes simplex, appearing at the site of previous infection.
Which assessment finding calls for the most immediate further assessment or interventions?
- A. Redness over the sacrum
- B. Bluish color around the earlobes and lips
- C. Dry, flaky skin
- D. Small, raised rash
Correct Answer: B
Rationale: Bluish color (cyanosis) indicates potential oxygenation issues, requiring immediate assessment and intervention.
An African-American male is discussing his dietary intake with the nurse. The nurse encourages the client to keep sodium intake below 1,500 mg per day. The client reports he does not have any known risk for the development of hypertension and feels this is too restrictive. How should the nurse respond?
- A. African-Americans typically have higher sodium levels than their Caucasian counterparts.'
- B. This is the amount of sodium intake recommended for everyone.'
- C. This is what will be best for you.'
- D. Do you eat a great deal of salt?'
Correct Answer: A
Rationale: After generations of conditioning, African-Americans frequently have higher sodium levels. The recommended sodium intake for African-Americans is slightly lower than for their Caucasian peers. Simply telling the client the recommendation is 'best' does not provide adequate information. The amount of salt ingested should be recorded, but this is not the best response.
The nurse manager of a medical-surgical unit is asked to determine if the unit should adopt a new care delivery system. Which behavior is an example of an autocratic style of leadership?
- A. Call a meeting and educate the staff on the new delivery system being used
- B. Organize a committee to investigate the various types of delivery systems
- C. Wait until another unit has implemented the new system and see if it works out
- D. Discuss with the nursing staff if a new delivery system should be adopted
Correct Answer: A
Rationale: Autocratic leadership involves unilateral decision-making and informing staff without input.
If a man burns his total left arm and half of the front of his chest, what percentage of his body is burned?
- A. 9%
- B. 18%
- C. 27%
- D. 36%
Correct Answer: B
Rationale: Using the Rule of Nines: left arm = 9%, half of anterior chest = 9% (full chest = 18%), total = 18%.