Nokea
Mr. Smith is 67-year-old black male brought to the hospital by his wife, who stated that he fell down 20 minutes ago and has been unable to speak or move his right side since then, Mr. Smith has no significant past medical history. On exam, Mr. Smith is conscious, very anxious, his speech is garbed and unintelligible, he has a left facial droop, and he is completely right hemiphlegic.
The most likely etiology for his symptoms is:
- A. CVA
- B. Traumatic brain injury
- C. Brain tumor
- D. Alzheimer's disease
Correct Answer: A
Rationale: Symptoms of sudden speech loss, facial droop, and hemiplegia strongly suggest a cerebrovascular accident (stroke).
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Which of the following is the primary force in sex education in a child's life?
- A. school nurse
- B. peers
- C. parents
- D. media
Correct Answer: C
Rationale: Parents are the primary influence on a child's sex education, providing foundational values and information. Other sources like peers and media are influential but secondary. Health Promotion and Maintenance
As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy?
- A. Decreased appetite
- B. Inadequate fluid intake
- C. Prolonged gastric emptying
- D. Reduced intestinal motility
Correct Answer: D
Rationale: During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause.
Teaching about the need to avoid foods high in potassium is most important for which client?
- A. a client receiving diuretic therapy
- B. a client with an ileus
- C. a client with metabolic alkalosis
- D. a client with renal disease
Correct Answer: D
Rationale: Renal disease impairs potassium excretion, leading to hyperkalemia, so avoiding high-potassium foods is critical. The other conditions are more associated with hypokalemia. Physiological Adaptation
A client's vision is to be evaluated using the Ishihara exam. The nurse recognizes that the client will be checked for:
- A. Macular degeneration
- B. Astigmatism
- C. Color blindness
- D. Glaucoma
Correct Answer: C
Rationale: The Ishihara exam tests for color blindness by assessing color perception. It does not evaluate macular degeneration, astigmatism, or glaucoma.
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?
- A. Chills
- B. Scant lochia rubra
- C. Thirst and fatigue
- D. Temperature of 100.2°F (37.9°C)
Correct Answer: B
Rationale: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4°F (38°C) also are common at 24 hours postpartum.