Nokea
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches
- B. Green drainage
- C. Reddened tissue
- D. Eschar development
Correct Answer: C
Rationale: Reddened tissue. Redness indicates granulation tissue formation, a sign of healing.
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A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
- A. Touching the abdomen could cause cancer cells to spread.'
- B. Examining the area would cause difficulty to the child.'
- C. Pushing on the stomach might lead to the spread of infection.'
- D. Placing any pressure on the abdomen may cause an abnormal experience.'
Correct Answer: A
Rationale: Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully.
The nurse is giving home care to a 69-year-old client who has severe arthritis. Which comment made by the client would indicate to the nurse that the client is experiencing normal changes associated with the aging process?
- A. I have such a hard time with the pain in my feet and knees.
- B. I have had loose stools for the last few months.
- C. My children say I keep my apartment too warm.
- D. I have a hard time at night because the lights are all big and fuzzy.
Correct Answer: C
Rationale: Feeling cold and preferring a warmer environment is a normal age-related change due to decreased thermoregulation. Pain, loose stools, and visual changes may indicate pathology requiring further investigation.
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
- A. They can expect the child will be mentally retarded
- B. Administration of thyroid hormone will prevent problems
- C. This rare problem is always hereditary
- D. Physical growth/development will be delayed
Correct Answer: B
Rationale: Administration of thyroid hormone will prevent problems. Early identification and continued treatment with hormone replacement corrects this condition.
The nurse is caring for a frail elderly client in her home. Which behavior, if observed or reported, should the nurse report to the supervisor for further evaluation of possible abuse?
- A. The client's daughter is attempting to be declared her mother's legal guardian.
- B. The client is frequently left in bed alone in the house for several hours at a time.
- C. The client has brown spots on her arms.
- D. The client says, 'My daughter doesn't like me very much. She yells at me.'
Correct Answer: B
Rationale: Leaving a frail client alone for hours poses neglect risk, warranting abuse evaluation. Guardianship, brown spots, or yelling are less definitive without context.
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidyl glycerol is noted. The nurse's assessment of this data is:
- A. The infant is at low risk for congenital anomalies.
- B. The infant is at high risk for intrauterine growth retardation.
- C. The infant is at high risk for respiratory distress syndrome.
- D. The infant is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 and presence of phosphatidyl glycerol suggest immature lungs, indicating a high risk for respiratory distress syndrome, so C is correct. Answers A, B, and D are not directly related to these findings.