Nokea
One of the following is a sign of right-sided heart failure of the patient
- A. tachypnea
- B. orthopnea
- C. wheezing
- D. pulmonary edema
Correct Answer: B
Rationale: Right-sided heart failure typically presents with systemic signs like orthopnea and peripheral edema rather than pulmonary edema.
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Which client has the highest risk for developing skin cancer?
- A. A 16-year old dark-skinned female who tans in tanning beds once a week
- B. A 65 year-old fair-skinned male who is a construction worker
- C. A 25 year-old dark-skinned male whose mother had skin cancer
- D. A 70 year-old fair-skinned female who works as a secretary
Correct Answer: B
Rationale: Fair-skinned individuals with prolonged sun exposure, such as construction workers, are at higher risk for skin cancer.
A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to 'freeze' and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond?
- A. Re-orient the client to his present location and circumstances
- B. Confirm that this is an effective technique to help with ambulation
- C. Assist the client to a carpeted area where he can walk more easily
- D. Plan to assess the client's cognition after returning to his room
Correct Answer: B
Rationale: Pretending to step over a crack is a known technique that can help clients with PD overcome freezing episodes.
Uncommon complications of severe falciparum malaria are:
- A. Stroke
- B. Anaemia
- C. Hepatitis
- D. Jaundice
Correct Answer: A
Rationale: The correct answer is A because stroke is an uncommon complication of severe falciparum malaria. The other options (b-e) are more common complications.
A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care?
- A. Altered urinary elimination
- B. Impaired gas exchange
- C. Fluid volume excess
- D. Decreased cardiac output
Correct Answer: C
Rationale: Hyponatremia (low sodium level) is often associated with fluid volume excess in clients with lung carcinoma.
A psychiatric referral is warranted in a preschool child with the following:
- A. Night terrors
- B. Separation anxiety
- C. Scared of ghosts
- D. Masturbation
Correct Answer: B
Rationale: Separation anxiety in a preschool child, especially if it is severe and persistent, may warrant a psychiatric referral to assess for anxiety disorders.