Nokea
The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
- A. Pain beneath the cast
- B. Warm toes
- C. Pedal pulses weak and rapid
- D. Paresthesia of the toes
Correct Answer: C
Rationale: Weak and rapid pedal pulses suggest compromised circulation, which requires immediate reporting to prevent complications like compartment syndrome.
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A 28-year-old woman pregnant with twins comes in for her prenatal appointment. She tells the nurse that she has two children at home (ages 4 years and 16 months), and she had one abortion 6 years ago when she was 8 weeks along in the pregnancy. The nurse charts
- A. gravida 4, para 2.
- B. gravida 4, para 3.
- C. gravida 5, para 2.
- D. gravida 5, para 3.
Correct Answer: C
Rationale: Gravida counts all pregnancies (2 children, 1 abortion, current twin pregnancy = 5). Para counts deliveries after 20 weeks (2 children = 2). Twins count as one delivery.
The nurse is preparing to teach a client about phenytoin sodium (Dilantin). Which fact would be most important to teach the client regarding why the drug should not be stopped suddenly?
- A. Physical dependence can develop over time.
- B. Status epilepticus can develop.
- C. A hypoglycemic reaction can develop.
- D. Heart block can develop.
Correct Answer: B
Rationale: Abruptly stopping phenytoin can precipitate status epilepticus, a life-threatening condition, due to loss of seizure control.
The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to:
- A. XII (hypoglossal)
- B. X (vagus)
- C. IX (glossopharyngeal)
- D. VII (facial)
Correct Answer: B
Rationale: The vagus nerve (X) innervates the pharynx and is responsible for the gag reflex, so its injury would cause an absent gag reflex.
The client with color blindness will most likely have problems distinguishing which of the following colors?
- A. Orange
- B. Violet
- C. Red
- D. White
Correct Answer: C
Rationale: Red-green color blindness is the most common type, making it difficult to distinguish red.
A client who is three days postpartum and is bottle-feeding her infant calls the nurse at the gynecology clinic with complaints of breast engorgement. What instruction should the nurse provide?
- A. reduce fluid intake to 1,500 ml/day
- B. take a warm shower twice a day
- C. apply a tight binder around her breasts
- D. come in to see the physician immediately as this is abnormal
Correct Answer: C
Rationale: A tight binder helps relieve breast engorgement by suppressing lactation in bottle-feeding mothers, a normal postpartum occurrence.