Nokea
Pressure ulcers usually occur:
- A. When clients are left in one position in bed for extended periods of time
- B. When clients are underweight
- C. When clients are overweight
- D. Only in underweight and overweight clients
Correct Answer: A
Rationale: Pressure ulcers occur over bony prominences due to decreased circulation from prolonged immobility, not specifically related to body weight.
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Physical examination of a client regarding mobility status should:
- A. begin with gait.
- B. be oriented to time, place, and person.
- C. begin with the Romberg test.
- D. begin with the Tandem Walk test.
Correct Answer: A
Rationale: Gait is usually assessed as the client walks into the room. Normal gait is smooth, flowing, and rhythmic without assistive devices.
People who live in poverty are most likely to obtain health care from:
- A. their primary care physician (family doctor)
- B. a neighborhood clinic
- C. specialists
- D. Emergency Departments or urgent care centers
Correct Answer: D
Rationale: Economic barriers often lead those in poverty to seek care from Emergency Departments or urgent care centers, which are more accessible than primary care or specialists.
Nail and foot care are essential in meeting basic hygiene needs of clients. Important assessments by the nurse in this area include:
- A. all body assessment, including the feet and nails.
- B. the essential lab work of the client.
- C. the nail beds and the tissue surrounding the nails.
- D. foot corns and calluses only.
Correct Answer: C
Rationale: The nail beds and the tissue surrounding the nails should be assessed for abnormal discoloration, lesions, paronychia (infection of tissue surrounding the nail), tissue dryness, breaks in the skin, pressure areas, or other abnormal appearances.
The nurse is observing the nursing student caring for the client with an artificial eye. What action by the student nurse would require intervention?
- A. Positioning the client lying down to remove the prosthetic eye
- B. Drying the prosthetic eye with gauze before reinsertion
- C. Cleansing the prosthetic eye with normal saline solution
- D. Telling the client to remove the prosthetic eye weekly for cleaning
Correct Answer: B
Rationale: B: The prosthetic eye should be moist to facilitate insertion; drying it could cause trauma to the socket. A: Lying down aids safe removal. C: Normal saline is appropriate for cleansing. D: Periodic removal every 1-3 weeks is recommended.
The client is in skeletal traction with 20 lb of traction applied to a right lower leg fracture. Which intervention should the nurse perform at regular intervals?
- A. Perform pin site care
- B. Remove the weights
- C. Reposition the right leg
- D. Perform passive ROM to the legs
Correct Answer: A
Rationale: A: Regular pin site care prevents infection. B: Weights are only removed in emergencies. C: Repositioning disrupts alignment. D: ROM is avoided to maintain traction.