Nokea
The home health nurse is caring for an 85-year-old client. It would require immediate follow-up if the client is reporting
- A. a painful red area on the buttocks
- B. new onset of dependent edema of the feet
- C. progressive loss of central vision
- D. no memory of activities performed yesterday
Correct Answer: A
Rationale: A painful red area on the buttocks suggests a pressure injury, requiring immediate intervention to prevent worsening. Edema, vision loss, and memory issues are concerning but less urgent.
You may also like to solve these questions
The nurse on a pediatric unit is caring for a 2-year-old client. Which of the following interventions are appropriate to reduce the distress of hospitalization on the child? Select all that apply.
- A. Encourage the parent to leave the child alone for short intervals
- B. Follow the child’s home sleep schedule and routine
- C. Integrate preferred snack foods into the child’s routine
- D. Point out body changes that may occur
- E. Provide various options when choosing toys
Correct Answer: B,C,E
Rationale: Maintaining sleep routines, offering preferred snacks, and providing toy choices reduce distress by promoting familiarity and autonomy. Leaving alone or discussing body changes may increase anxiety.
The nurse is assisting at a disaster shelter setup following a devastating earthquake. What is the most common problem the nurse is likely to see in those who come to the shelter?
- A. Thirst
- B. Traumatic injuries
- C. Stress
- D. Exacerbation of medical problems
Correct Answer: C
Rationale: Stress is the most common issue post-disaster due to trauma and displacement, affecting most survivors. Thirst, injuries, or medical exacerbations are less universal.
On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the registered nurse (RN) anticipate?
- A. Periorbital edema, absent light reflex and translucent tympanic membrane
- B. Irritability, rhinorrhea, and bulging tympanic membrane
- C. Diarrhea, fever, and reddened tympanic membrane
- D. Vomiting, pulling at ears and pearly white tympanic membrane
Correct Answer: B
Rationale: Irritability, rhinorrhea, and bulging tympanic membrane. These findings are characteristic of otitis media, indicating infection and inflammation of the middle ear.
An adult has both an oil retention enema and a cleansing enema ordered. The nurse knows that this client is most likely to have which condition/ problem?
- A. Straining while defecating
- B. Melena
- C. Ulcerative colitis
- D. Fecal impaction
Correct Answer: D
Rationale: Oil retention enemas soften hardened stool, and cleansing enemas remove it, making this combination most appropriate for fecal impaction. Straining, melena, or ulcerative colitis are less likely to require both types of enemas.
Which nursing intervention is most critical during the administration of Acyclovir (Zovirax)?
- A. Limit the client's activity.
- B. Encourage a high-carbohydrate diet.
- C. Utilize an incentive spirometer to improve respiratory function.
- D. Encourage fluids.
Correct Answer: D
Rationale: Acyclovir can cause renal toxicity; encouraging fluids promotes renal perfusion and reduces risk of crystal formation in the kidneys.