Nokea
The clinic nurse is returning client calls. Which client should the nurse call first?
- A. The 39-year-old client complaining of headache pain with a 3 on the pain scale.
- B. The 45-year-old client who needs a prescription refill for warfarin.
- C. The 54-year-old client diagnosed with diabetes type 1 who has been vomiting.
- D. The 60-year-old client who cannot afford to buy food and needs assistance.
Correct Answer: C
Rationale: Vomiting in a type 1 diabetic risks diabetic ketoacidosis, a medical emergency, requiring immediate attention. Headache, warfarin refill, and food insecurity are less urgent.
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The client is diagnosed with salmonellosis secondary to eating some slightly cooked hamburger meat. Which clinical manifestations should the nurse expect the client to report?
- A. Abdominal cramping, nausea, and vomiting.
- B. Neuromuscular paralysis and dysphagia.
- C. Gross amounts of explosive bloody diarrhea.
- D. Frequent 'rice water stool' with no fecal odor.
Correct Answer: A
Rationale: Salmonellosis typically causes abdominal cramping, nausea, and vomiting due to bacterial irritation of the GI tract. Paralysis is botulism, bloody diarrhea is more typical of other pathogens, and rice water stool is cholera.
The client asks how he contracted hepatitis A. He reports all of the following. Which one is most likely related to hepatitis A?
- A. He ate home-canned corn.
- B. He ate oysters his roommate brought home from a fishing trip.
- C. He stepped on a nail two weeks ago.
- D. He donated blood two weeks before he got sick.
Correct Answer: B
Rationale: Hepatitis A is transmitted via the fecal-oral route, often through contaminated food like oysters. Oysters from unsafe waters are a common source.
Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis?
- A. Twenty bloody stools a day.
- B. Oral temperature of 102°F.
- C. Hard, rigid abdomen.
- D. Urinary stress incontinence.
Correct Answer: A
Rationale: Ulcerative colitis commonly causes frequent bloody stools due to inflammation and ulceration of the colon mucosa. Fever may occur but is less specific, a hard abdomen suggests complications like perforation, and urinary incontinence is unrelated.
Which problem is most appropriate for the nurse to identify for the client with diarrhea?
- A. Alteration in skin integrity.
- B. Chronic pain perception.
- C. Fluid volume excess.
- D. Ineffective coping.
Correct Answer: A
Rationale: Diarrhea can cause perianal skin breakdown, making alteration in skin integrity the most appropriate problem. Pain is less common, fluid volume is deficient, and coping is secondary.
The 85-year-old male client diagnosed with cancer of the colon asks the nurse, 'Why did I get this cancer?' Which statement is the nurse's best response?
- A. Research shows a lack of fiber in the diet can cause colon cancer.
- B. It is not common to get colon cancer at your age; it is usually in young people.
- C. No one knows why anyone gets cancer, it just happens to certain people.
- D. Women usually get colon cancer more often than men but not always.
Correct Answer: A
Rationale: Low dietary fiber is a known risk factor for colon cancer, as it slows bowel transit and increases exposure to carcinogens. Colon cancer is common in older adults, not younger ones, and gender differences are minimal.