Nokea
The client presents to the emergency room with a hyphema. Which action by the nurse would be appropriate?
- A. Elevate the head of the bed and apply ice to the eye.
- B. Place the client in a supine position and apply heat to the knee.
- C. Insert a Foley catheter and measure the intake and output.
- D. Perform a vaginal exam and check for a discharge.
Correct Answer: A
Rationale: A hyphema (blood in the anterior chamber of the eye) requires elevating the head to reduce intraocular pressure and applying ice to decrease swelling. The other actions are irrelevant to hyphema management.
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A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
- A. Okay, missing one meal won't hurt.'
- B. You'll have to eat lunch, or we'll force-feed you.'
- C. It's not appropriate for you to try to manipulate the staff into granting your wishes.'
- D. We will not allow you to starve yourself. You may choose to eat voluntarily or be fed.'
Correct Answer: D
Rationale: Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client an increased sense of control over her life and avoid an argument or power struggle.
The nurse is caring for an older client hospitalized with dehydration. Which site should be used to check for skin turgor?
- A. Hand
- B. Arm
- C. Abdomen
- D. Forehead
Correct Answer: C
Rationale: In older adults the abdomen is the most reliable site for assessing skin turgor due to age-related changes in skin elasticity on the hands and arms. The forehead is not a standard site for this assessment.
An elective saline abortion has been performed on a 3-week primigravida. Following the procedure, the nurse should be alert for which early side effect?
- A. Water satiety
- B. Thirst
- C. Edema
- D. Diabetes insipidus
Correct Answer: B
Rationale: Saline absorption into the bloodstream increases serum sodium, leading to thirst as an early side effect.
In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?
- A. Striae gravidarum
- B. Chloasma
- C. Dysuria
- D. Colostrum
Correct Answer: C
Rationale: Dysuria is abnormal and may indicate a urinary tract infection, unlike the other options, which are normal pregnancy changes.
A client in labor admits to using alcohol throughout the pregnancy. The most recent use was the day before. Based on the client's history, the nurse should give priority to assessing the newborn for:
- A. Respiratory depression
- B. Wide-set eyes
- C. Jitteriness
- D. Low-set ears
Correct Answer: C
Rationale: Fetal alcohol exposure, especially recent use, can cause neonatal withdrawal symptoms like jitteriness. Respiratory depression is less common, and physical anomalies like wide-set eyes or low-set ears are associated with chronic exposure.