Nokea
The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments?
- A. Interstitial compartment.
- B. Intravascular compartment.
- C. Extracellular compartment.
- D. Intracellular compartment.
Correct Answer: C
Rationale: These symptoms indicate fluid excess in the extracellular compartment, which includes interstitial spaces (edema) and intravascular spaces (contributing to lung crackles).
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A 13-year-old client is dying of cancer and struggling with the emotional aspects of this. When providing care for this client, the nurse should incorporate the developmental tasks for this age. According to Erikson's developmental model, the child normally is expected to be working on which of the following psychosocial issues?
- A. Identity vs. role confusion.
- B. Intimacy vs. isolation.
- C. Industry vs. inferiority.
- D. Autonomy vs. shame and doubt.
Correct Answer: A
Rationale: Adolescents (ages 12–18) focus on identity vs. role confusion, developing a sense of self and personal identity.
The nurse is caring for a client with a suspected stroke. Which assessment should the nurse perform first?
- A. Check blood glucose levels
- B. Assess pupil response
- C. Evaluate speech and motor function
- D. Monitor blood pressure
Correct Answer: C
Rationale: Evaluating speech and motor function first helps confirm stroke symptoms using tools like the FAST scale, guiding urgent intervention.
The nurse is caring for a client with a history of deep vein thrombosis who is prescribed enoxaparin (Lovenox). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild bruising.
- B. Bleeding gums.
- C. Headache.
- D. Nausea.
Correct Answer: B
Rationale: Bleeding gums indicate a potential bleeding complication with enoxaparin, requiring immediate reporting.
A client with a history of ulcerative colitis is prescribed sulfasalazine (Azulfidine). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Avoid sun exposure.
- C. Stop the medication if diarrhea resolves.
- D. Take the medication on an empty stomach.
Correct Answer: B
Rationale: Sulfasalazine can cause photosensitivity, so clients should avoid sun exposure.
While assisting the physician with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?
- A. Intrauterine infection.
- B. Fetal meconium staining.
- C. Erythroblastosis fetalis.
- D. Normal amniotic fluid.
Correct Answer: B
Rationale: Cloudy, thick amniotic fluid often indicates meconium staining, suggesting fetal distress, which requires further evaluation.