Nokea
How would you confirm a client has heard instructions if they nod yes to everything?
- A. Ask them to repeat the instructions back
- B. Provide written instructions
- C. Observe their behavior during implementation
- D. All of the above
Correct Answer: D
Rationale: Multiple methods ensure understanding and retention of the information.
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A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For
which of the following client findings should the nurse intervene first?
- A. Urticaria
- B. Stridor
- C. Vomiting
- D. Hypotension
Correct Answer: B
Rationale: The correct answer is B: Stridor. Stridor is a high-pitched, inspiratory sound that indicates upper airway obstruction and impending respiratory distress, which is a life-threatening complication of anaphylaxis. The nurse should intervene first by ensuring a patent airway to prevent respiratory compromise. Urticaria (A) is a common symptom of an allergic reaction but does not pose an immediate threat to airway patency. Vomiting (C) can be a sign of gastrointestinal distress but does not require immediate intervention for airway protection. Hypotension (D) is a serious manifestation of anaphylaxis but addressing airway obstruction takes precedence to prevent respiratory failure.
Which eating disorder involves self-starvation?
- A. Binge-eating disorder
- B. Bulimarexia
- C. Bulimia nervosa
- D. Anorexia nervosa
Correct Answer: D
Rationale: Anorexia nervosa is characterized by extreme calorie restriction and self-starvation.
What general appearance and obvious physical characteristic components should the nurse evaluate when completing a biocultural assessment?
- A. Skin color,bone structure and eye shape.
- B. Mobility and gait.
- C. Behavioral patterns.
- D. All of the above.
Correct Answer: D
Rationale: Evaluating multiple aspects of physical appearance provides a comprehensive understanding of the client's biocultural context.
Sue is diagnosed with congestive heart failure. What medication would you expect to administer to strengthen myocardial contractility?
- A. Nitroprusside.
- B. Digoxin.
- C. Nitroglycerine ointment.
- D. Furosemide.
Correct Answer: B
Rationale: Digoxin enhances myocardial contractility in CHF.
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
- A. Observe for edema proximal to the site.
- B. Irrigate with 5 mls of 0.9% Normal Saline.
- C. Palpate for a thrill over the fistula.
- D. Check color and warmth in the extremity.
Correct Answer: C
Rationale: A thrill confirms blood flow through the fistula.