Nokea
One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. Which of the following indicates that the client has attained the goal? The client has:
- A. Regained weight loss.
- B. Resumed normal dietary intake of three meals a day.
- C. Controlled nausea and vomiting through regular use of antiemetics.
- D. Achieved optimal nutritional status through oral or parenteral feedings.
Correct Answer: D
Rationale: Achieving optimal nutritional status, whether through oral or parenteral feedings, is the primary goal one month post-gastrectomy, as it indicates the client is meeting nutritional needs.
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At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia?
- A. Early in the morning, when the client's energy level is high.
- B. To coincide with the peak action of drug therapy.
- C. Immediately after a rest period.
- D. When family members will be available.
Correct Answer: B
Rationale: Scheduling activities during peak drug action (e.g., levodopa) maximizes mobility and reduces hypokinesia. Morning energy, rest periods, or family availability are less directly tied to symptom control.
The nurse is preparing a 3-year-old child for an incision and drainage of a large left leg abscess. The nurse understands which of the following types of anesthesia will be administered to the child?
- A. Peripheral nerve block
- B. Spinal anesthesia
- C. General Anesthesia
- D. Local Anesthesia
Correct Answer: C
Rationale: General anesthesia is typically used for young children undergoing procedures like incision and drainage to ensure safety and comfort.
Which of the following is an environmental factor and increases the risk of cancer?
- A. Gender.
- B. Nutrition.
- C. Immunologic status.
- D. Age.
Correct Answer: B
Rationale: Nutrition is an environmental factor that influences cancer risk, as diets high in processed foods or low in fiber can increase the risk of cancers like colon cancer.
What is the earliest clinical manifestation in a client with acute disseminated intravascular coagulation (DIC)?
- A. Severe shortness of breath.
- B. Bleeding without history or cause.
- C. Orthopnea.
- D. Hematuria.
Correct Answer: B
Rationale: DIC causes widespread clotting and bleeding due to consumption of clotting factors and platelets. The earliest manifestation is often unexplained bleeding, such as petechiae or oozing from venipuncture sites. Shortness of breath, orthopnea, and hematuria are later or less specific signs.
The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following?
- A. The client's shoulders shrug against downward pressure of the examiner's hands.
- B. The client's arm pulls up from a resting position against resistance.
- C. The client's arm straightens out from a flexed position against resistance.
- D. The client's hand-grasp strength is equal.
Correct Answer: A
Rationale: A C8 fracture affects the lower cervical nerves, but shoulder shrug (trapezius, innervated by cranial nerve XI and C3-C4) should remain intact. Arm movements and hand grasp involve C5-C8 and may be impaired, making shoulder shrug the most reliable intact movement to document.