Nokea
The nurse should recognize that which of the following findings is a complication of immobility
- A. Increased BP
- B. Urinary frequency
- C. Swollen area on calf
Correct Answer: C
Rationale: The correct answer is C: Swollen area on calf. Immobility can lead to blood pooling in the lower extremities, causing swelling, pain, and potentially leading to deep vein thrombosis (DVT). This is a serious complication that can result from prolonged periods of immobility. Increased blood pressure (choice A) is not typically a direct complication of immobility. Urinary frequency (choice B) is more commonly associated with conditions like urinary tract infections or overactive bladder, not immobility. Swollen area on the calf (choice C) is a hallmark sign of potential DVT in immobile patients.
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Fill in the blanks with one condition and one client finding.The client is most likely experiencing---------- as evidenced by the client's--------
- A. Mania
- B. Delirium
- C. Catatonia
- D. Magical thinking
- E. Euphoric mood
- F. Hypervigilance
- G. Panic disorder
Correct Answer: A,E
Rationale: The correct answer is A, E. Mania is characterized by elevated mood, increased energy levels, and impulsivity. The client is most likely experiencing mania as evidenced by euphoric mood. Euphoric mood is a key symptom of mania, reflecting a heightened sense of well-being and happiness. Therefore, the combination of mania and euphoric mood is indicative of a manic episode. Choices B, C, D, F, and G are incorrect as they do not align with the symptoms and presentation of mania. Delirium is characterized by confusion and disorientation, not euphoric mood. Catatonia involves motor disturbances, not euphoric mood. Magical thinking refers to unrealistic beliefs, not necessarily elevated mood. Hypervigilance is associated with anxiety disorders, not mania. Panic disorder is characterized by recurrent panic attacks, not euphoric mood.
Nurse reviews the assessment findings. Which findings require immediate follow-up?
- A. Right forearm and fingers are edematous.
- B. Ecchymotic area noted on outer aspect of the forearm.
- C. Heart rate 102/min
- D. Fingers slightly cool to touch.
- E. Child verbalizes a pain level of 4 on a scale of 0 to 10
- F. Respiratory rate 22/min
Correct Answer: A,D
Rationale: Edema and coolness in the extremity suggest circulatory impairment, warranting immediate attention.
Which of the following food choices is appropriate for this client?
- A. Canned barley soup
- B. Potato pancakes.
- C. Wheat crackers
- D. White flour tortillas
Correct Answer: B
Rationale: The correct answer is B: Potato pancakes. This choice is appropriate as it is likely to be well-tolerated by the client. Potatoes are a good source of carbohydrates and can provide energy. Additionally, potato pancakes are easy to digest and can be a good option for someone with digestive issues. On the other hand, A, C, and D contain grains that may be harder to digest for some individuals, especially if they have digestive concerns. Canned barley soup (A) may also contain added preservatives and sodium, which may not be ideal for the client's condition. Wheat crackers (C) can be high in fiber and may be difficult to digest. White flour tortillas (D) are made from refined grains and may not provide the necessary nutrients for the client.
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A,C,F,G
Rationale: The correct answers (A, C, F, G) indicate potential prenatal complications. Urine protein (A) suggests preeclampsia, a serious condition characterized by high blood pressure (C) and proteinuria. Headaches (F) can also be a sign of preeclampsia. Gravida/parity (G) provides important obstetric history, identifying high-risk pregnancies. Fetal activity (B) and respiratory rate (E) are not specific to prenatal complications. Urine ketones (D) may indicate dehydration but not necessarily a prenatal complication.
Nurse is planning care for a child during admission to the facility. Which action should the nurse take first?
- A. Obtain a prescription for pain medication.
- B. Collect blood cultures
- C. Transport the child to obtain a CT scan.
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: Positive Brudzinski's and Kernig's signs indicate meningitis, making seizure precautions the priority to prevent complications.