Nokea
On assessment of the abdomen in a patient with peritonitis, you would expect to find
- A. A soft abdomen with bowel sounds every 2 to 3 seconds.
- B. Rebound tenderness and guarding (protecting).
- C. Hyperactive, high-pitched bowel sounds and a firm abdomen.
- D. Ascites and increased vascular pattern on the skin.
Correct Answer: B
Rationale: Peritonitis causes rebound tenderness and guarding due to inflammation of the peritoneum.
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What prevents disorientation in older clients with hearing impairments?
- A. Use of written notes and a walking cane for proper balance
- B. Refer to a local support or self-help group
- C. Frequent contact and reorientation
- D. Avoid frequent outdoor activities
Correct Answer: C
Rationale: Regular reorientation and interaction help maintain cognitive and spatial awareness.
A patient who received spinal anesthesia four hours ago during surgery is transferred to the surgical unit and, after 90 minutes, now reports severe incisional pain. The patient's blood pressure is 170/90 mmHg, pulse is 108 beats/min, temperature is 99oF (37.2oC), and respirations are 30 breaths/min. The patient's skin is pale, and the surgical dressing is dry and intact. The most appropriate nursing intervention is to
- A. medicate the patient for pain.
- B. place the patient in a high Fowler position and administer oxygen.
- C. place the patient in a reverse Trendelenburg position and open the IV line.
- D. report the findings to the provider.
Correct Answer: D
Rationale: The nurse should report these findings to the provider because the patient may be experiencing complications such as hypertension or hypovolemia.
Which traits are clients with anorexia nervosa noted to have?
- A. Low self-esteem
- B. High self-esteem
- C. Perfectionism
- D. Intense desire to displease others
Correct Answer: C
Rationale: Perfectionism is a common trait among individuals with anorexia nervosa, driving their pursuit of unrealistic body ideals.
What are the priority medical interventions for a client experiencing shock?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.
Place the following interventions in the correct order.
- A. Apply a loose, sterile, bulky dressing
- B. Give pain medication
- C. Remove the victim from the cold environment
- D. Immerse the feet in warm water 100°F to 105°F (40.6°C to 46.1°C)
Correct Answer: C
Rationale: The first priority is removing the victim from the cold environment to prevent further damage.