Nokea
The nurse assesses the assigned clients for the shift. Of the following assigned clients, which client is at greatest risk for falling?
- A. A 22-year-old man with three fractured ribs and a fractured left arm.
- B. A 70-year-old woman with episodes of syncope.
- C. A 50-year-old man with angina.
- D. A 30-year-old woman with a fractured ankle.
Correct Answer: B
Rationale: Syncope increases fall risk due to sudden loss of consciousness, particularly in an elderly client with potential comorbidities.
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The nurse is teaching a client with a new diagnosis of epilepsy about self-care. Which of the following instructions should be included?
- A. Avoid swimming alone.
- B. Take medications at bedtime only.
- C. Limit fluid intake to prevent seizures.
- D. Wear loose-fitting clothing.
Correct Answer: A
Rationale: Avoiding swimming alone prevents drowning during a seizure, a key safety measure.
The nurse is performing an assessment on a client with a diagnosis of systemic lupus erythematosus (SLE). Which finding should the nurse expect to note? Select all that apply.
- A. Fever
- B. Bradycardia
- C. Lymphadenopathy
- D. Butterfly rash on the face
- E. Muscular aches and pains
Correct Answer: A,C,D,E
Rationale: Manifestations of SLE may include fever, musculoskeletal aches and pains, butterfly rash on the face, pleural effusion, basilar pneumonia, generalized lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, seizures, psychosis, and coma.
The nurse is evaluating the laboratory results of a client who was recently admitted to the hospital. Which one of the following results indicates the presence of inflammation?
- A. Decreased sedimentation rate
- B. Thrombocytopenia
- C. Leukocytosis
- D. Erythrocytosis
Correct Answer: C
Rationale: Leukocytosis, an elevated white blood cell count, indicates inflammation or infection. Decreased sedimentation rate, thrombocytopenia, and erythrocytosis are not specific to inflammation.
A client with a history of chronic kidney disease is prescribed calcitriol (Rocaltrol). The nurse should instruct the client to:
- A. Monitor for signs of hypercalcemia.
- B. Take the medication on an empty stomach.
- C. Avoid phosphorus-rich foods.
- D. Stop the medication if nausea occurs.
Correct Answer: A
Rationale: Calcitriol can cause hypercalcemia, requiring monitoring for symptoms like confusion.
A nurse who fails to check a client's armband before administering his medications is:
- A. Negligent.
- B. Following standard procedure.
- C. Acting within their scope of practice.
- D. Exercising professional judgment.
Correct Answer: A
Rationale: Failing to check a client's armband before administering medications is negligent, as it violates patient safety protocols for verifying identity.