Nokea
The client with a left-sided mastectomy is diagnosed with elephantiasis of the left arm. Which signs/symptoms should the nurse expect to assess?
- A. Edematous arm from the axillary area to the fingertips.
- B. Painful, edematous, reddened lower forearm.
- C. Tented skin turgor over the entire left arm.
- D. Nipple retraction and peau d’orange skin.
Correct Answer: A
Rationale: Elephantiasis causes chronic lymphedema, leading to arm edema from axilla to fingertips (A). Pain/redness (B) suggests infection, tented turgor (C) is dehydration, and nipple changes (D) are breast cancer signs.
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The nurse is teaching a client with endocarditis about preventing recurrence. Which statement is most important?
- A. You need antibiotics before dental procedures.
- B. You should avoid all vaccinations.
- C. You can stop antibiotics if you feel better.
- D. You should limit fluid intake.
Correct Answer: A
Rationale: Prophylactic antibiotics before dental procedures prevent bacterial seeding of heart valves.
The client with aortic stenosis asks why they feel tired. What is the best response?
- A. Your heart is not pumping enough blood.
- B. Your lungs are retaining fluid.
- C. Your blood pressure is too high.
- D. Your heart rate is too slow.
Correct Answer: A
Rationale: Aortic stenosis restricts blood flow from the heart, reducing cardiac output and causing fatigue.
Which complication should the nurse monitor for in a client with cardiomyopathy?
- A. Heart failure
- B. Hypoglycemia
- C. Osteoporosis
- D. Gastritis
Correct Answer: A
Rationale: Cardiomyopathy impairs heart function, increasing the risk of heart failure.
Which instruction should the nurse discuss with the client diagnosed with Raynaud's phenomenon?
- A. Explain exacerbations will not occur in the summer.
- B. Use nicotine gum to help quit smoking.
- C. Wear extra-warm clothing during cold exposure.
- D. Avoid prolonged exposure to direct sunlight.
Correct Answer: C
Rationale: Cold triggers Raynaud’s; wearing warm clothing (C) prevents vasospasm. Exacerbations occur in summer (A), nicotine gum (B) still delivers nicotine (harmful), and sunlight (D) is irrelevant.
The unlicensed assistive personnel (UAP) is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse?
- A. Removing compression stockings before assisting the client to bed.
- B. Taking the client’s blood pressure manually after using the machine.
- C. Assisting the client by opening the milk carton on the lunch tray.
- D. Calculating the client’s shift intake and output with a pen and paper.
Correct Answer: A
Rationale: Removing compression stockings (A) at night is incorrect; they should be worn to reduce edema. Manual BP (B), opening cartons (C), and I/O Calculation(ans only)s (D) are appropriate.