Nokea
Immediately after surgery the client with an above-the-knee amputation of the right leg refuses to look at the operative site. The most immediate diagnosis that can be made is:
- A. Self-care deficit
- B. Potential for infection
- C. Disturbance in self-concept
- D. Cognitive deficit
Correct Answer: C
Rationale: Refusing to look at the operative site suggests a disturbance in self-concept, as the client may be struggling with acceptance of the altered body image post-amputation.
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The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client's progress, the nurse recognizes that the most revealing resistant behavior is
- A. Recurring crises
- B. Continuing drug use
- C. Rationalizing comments
- D. Missing appointments
Correct Answer: B
Rationale: Continuing drug use. Persistent substance use indicates lack of commitment to recovery and ongoing addiction.
A client after right cataract surgery.
The nurse would intervene in which of the following situations?
- A. Client is in the supine position.
- B. The head of the bed is elevated 30°.
- C. The client is lying on her right side.
- D. An eye shield is over the right eye.
Correct Answer: C
Rationale: Strategy: 'Nurse would intervene' indicates an incorrect action. (1) appropriate position (2) decreases swelling and pain (3) correct-client should not be positioned with operative side in a dependent position or against the bed (4) shield is appropriate
During a prenatal visit, a client states: 'I have been very nauseated during my first trimester, and I don't understand the reason.' Which of the following responses by the nurse is BEST?
- A. You are nauseated because of the fatigue you are feeling.'
- B. The nausea is due an increase in the basal metabolic rate.'
- C. The nausea is caused by a secondary elevation in the hormones produced by the endocrine system.'
- D. If you eat different kinds of foods, you won't be nauseated.'
Correct Answer: C
Rationale: during first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system
A client with severe bilateral peripheral edema.
Which of the following is the BEST way for the nurse to determine the degree of edema in a limb, and the client's response to treatment?
- A. Measure both limbs with the tape measure and compare.
- B. Depress the skin and rank the degree of pitting.
- C. Describe the swelling in the affected area.
- D. Pinch the skin and note how quickly it returns to normal.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not the best way to evaluate for peripheral edema (2) correct-severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting) (3) not as objective (4) is used for evaluating hydration
A diabetic client is taking Lantus insulin for regulation of his blood glucose levels. The nurse should know that this insulin will most likely be administered:
- A. Prior to each meal
- B. At night
- C. Midday
- D. Prior to the evening meal
Correct Answer: B
Rationale: Lantus is a long-acting insulin typically administered at night to provide basal coverage. Options A, C, and D are incorrect for its dosing schedule.