Nokea
The client is admitted with a diagnosis of acute pancreatitis. Which position is most comfortable for the client?
- A. Supine
- B. Prone
- C. Fowler’s
- D. Side-lying with knees flexed
Correct Answer: D
Rationale: Side-lying with knees flexed reduces pressure on the inflamed pancreas, providing comfort in acute pancreatitis. Supine, prone, and Fowler’s positions may increase discomfort.
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A client's wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson's disease, and she is telling his nurse that he has been doing 'strange things.' The nurse reassures the wife that the following behavior is normal with Parkinson's disease:
- A. Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods.'
- B. Your husband may move his hands in motions that look like he is rolling a pill between his fingers.'
- C. Twitching of the muscles is to be expected and can occur at any time during the day.'
- D. Parkinson's disease causes severe pain in the joints. You should give your husband Tylenol at those times.'
Correct Answer: B
Rationale: Clients with Parkinson's disease generally experience stiffness and rigid movement. Pill-rolling movements are a symptom experienced by the Parkinson client. Twitching of the muscles is not an expected symptom of Parkinson's disease. Parkinson's disease does not cause joint pain. Mild muscular pain may be present.
While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
- A. Discontinue the central line.
- B. Begin a peripheral IV.
- C. Document in the nurse's notes and notify the physician after redressing the site.
- D. Clean the site well and redress.
Correct Answer: C
Rationale: The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued.
The nurse is caring for a client with a spinal cord injury at C5. Which complication is the client at greatest risk for?
- A. Respiratory depression
- B. Autonomic dysreflexia
- C. Pressure ulcers
- D. Deep vein thrombosis
Correct Answer: A
Rationale: A C5 spinal cord injury impairs diaphragm function (innervated by C3–C5), placing the client at greatest risk for respiratory depression due to weak respiratory muscles. The other complications are risks but less immediate.
An appropriate nursing intervention for the client with borderline personality disorder is:
- A. Observing the client for signs of depression or suicidal thinking
- B. Allowing the client to lead unit group sessions
- C. Restricting the client's activity to the assigned unit of care throughout hospitalization
- D. Allowing the client to select a primary caregiver
Correct Answer: A
Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.
The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse knows that RhoGam is given at:
- A. One finger breadth below the umbilicus
- B. The deltoid
- C. Two finger breadths above the trochanter
- D. Two finger breadths below the umbilicus
Correct Answer: B
Rationale: RhoGam is administered intramuscularly, typically in the deltoid muscle, for Rh-negative mothers to prevent sensitization. The other locations are incorrect for IM injections of RhoGam.