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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Which of the following individuals may legally give informed consent?
- A. an 86-year-old male with advanced Alzheimer's disease
- B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- C. a 72-year-old female scheduled for a heart transplant
- D. a 6-month-old baby needing bowel surgery
Correct Answer: C
Rationale: Only competent adults can legally give informed consent. The 72-year-old female is presumed competent unless stated otherwise. An individual with advanced Alzheimer's lacks decision-making capacity, a non-emancipated minor cannot consent, and infants are legally incapable of consenting; their guardians must provide consent.
In evaluating the lab work of a client in a hepatic coma, which of the following lab tests is most important?
- A. Blood urea nitrogen
- B. Serum calcium
- C. Serum ammonia
- D. Serum creatinine
Correct Answer: C
Rationale: Elevated serum ammonia is critical in hepatic coma, as liver failure impairs ammonia metabolism, causing brain-tissue irritation.
The death of a beloved spouse places the surviving partner in which type of crisis?
- A. maturational
- B. reactive
- C. nonreactive
- D. situational
Correct Answer: D
Rationale: A situational crisis is an unexpected, unplanned event, such as the death of a spouse. Option 1 is a normal maturational crisis; Choices 2 and 3 are not recognized crisis states.
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 LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?
- A. Assist the client to a sitting position at the edge of the bed.
- B. Have the client march in place for 30 seconds.
- C. Have the client raise his arms above his head.
- D. Ask the client the last time he fell.
Correct Answer: A
Rationale: The client should be assisted to a sitting position prior to standing. This action can prevent orthostatic hypotension. Marching in place and raising the client's arms above his head are not necessary prior to ambulation. While knowing about the client's last fall can be important, it is not the priority action before ambulating the client.