Nokea
A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?
- A. Cool skin
- B. Numbness
- C. Pallor
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. Thrombophlebitis is inflammation of a vein with a blood clot, leading to impaired blood flow. Edema, or swelling, is a common symptom due to the obstruction of blood flow. This results in fluid accumulation in the affected area. Cool skin, numbness, and pallor are not typical findings in thrombophlebitis. Cool skin and numbness are more indicative of nerve or circulation issues, while pallor suggests reduced blood flow but is not a common finding in thrombophlebitis.
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A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?
- A. Inability to regulate body temperature
- B. Bradycardia
- C. Visual disturbances
- D. Inability to perceive sound
Correct Answer: A
Rationale: The correct answer is A: Inability to regulate body temperature. The hypothalamus plays a crucial role in regulating body temperature. Surgery near this area can disrupt its function, leading to potential problems in thermoregulation. The nurse should monitor the client for signs of hyperthermia or hypothermia. Bradycardia (choice B) is more related to dysfunction in the cardiovascular system, not typically affected by surgery near the hypothalamus. Visual disturbances (choice C) and inability to perceive sound (choice D) are more associated with areas of the brain responsible for processing sensory information, not specifically linked to the hypothalamus.
A nurse is caring for a client who has a respiratory infection. When the client asks how the position the nurse put him in can help, the nurse should explain that lying on his left side in Trendelenburg position helps mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Postural drainage uses gravity to mobilize mucus from different lung segments, aiding in secretion clearance.
A nurse is caring for a client whose belongings were lost in a hurricane. The client says, 'What's the use in starting over? It will probably happen again.' Which of the following responses should the nurse make?
- A. I am sure everything will work out.'
- B. It appears you are feeling hopeless.'
- C. It is probably not as bad as you think.'
- D. I would not worry about what can't be changed.'
Correct Answer: B
Rationale: Acknowledging feelings of hopelessness is therapeutic and encourages the client to express emotions.
A nurse is performing wound care for an older adult client who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?
- A. Transparent
- B. Wet-to-dry
- C. Dry, sterile
- D. Antimicrobial
Correct Answer: A
Rationale: Transparent dressings protect stage I pressure ulcers while allowing for visualization of the wound.
A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- A. Excessive laxative use
- B. Ignoring the urge to defecate
- C. Inadequate fluid intake
- D. Increased fiber in the diet
- E. Increased activity
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. A: Excessive laxative use can lead to constipation by causing dependency on laxatives. B: Ignoring the urge to defecate can disrupt the normal bowel movement pattern, leading to constipation. C: Inadequate fluid intake can result in hard, dry stools that are difficult to pass, causing constipation. D: Increased fiber in the diet actually helps prevent constipation by adding bulk to the stool. E: Increased activity generally promotes bowel regularity and helps prevent constipation. By discussing A, B, and C with the client, the nurse can address common causes of constipation and provide appropriate interventions.