Nokea
The nurse explains to the client that the main reason a back rub is used as therapy to relieve pain is because the massage:
- A. Blocks pain impulses from the spinal cord to the brain.
- B. Blocks pain impulses from the brain to the spinal cord.
- C. Stimulates the release of endorphins.
- D. Distracts the client's focus on the source of the pain.
Correct Answer: C
Rationale: Massage, like a back rub, stimulates endorphin release, which naturally reduces pain perception. It does not block pain impulses directly or act solely as a distraction.
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A client with peripheral vascular disease has chronic, severe pretibial and ankle edema bilaterally. Because the client is on complete bed rest and circulation is compromised, one goal is to maintain tissue integrity. Which of the following interventions will help achieve this outcome?
- A. Administering pain medication
- B. Encouraging fluids
- C. Turning the client every 1 to 2 hours
- D. Maintaining hygiene
Correct Answer: C
Rationale: Turning the client every 1 to 2 hours prevents pressure ulcers by relieving pressure on dependent areas, promoting circulation, and maintaining skin integrity in a client with PVD and edema on bed rest. Pain medication, fluids, and hygiene are important but do not directly address tissue integrity.
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after the cystoscopy?
- A. Dizziness.
- B. 2. skills.
- C. Pink-tinged urine.
- D. Bladder spasms.
Correct Answer: D
Rationale: Bladder spasms post-cystoscopy indicate a complication, often due to irritation or trauma to the bladder lining, requiring medical attention. Pink-tinged urine is expected, and dizziness may relate to other causes.
Which activity increases the risk of renal calculi?
- A. High fluid intake.
- B. Sedentary lifestyle.
- C. Low-sodium diet.
- D. Frequent urination.
Correct Answer: B
Rationale: A sedentary lifestyle promotes urinary stasis, increasing stone risk.
Which of the following is normal for a client during the icteric phase of viral hepatitis?
- A. Tarry stools.
- B. Yellowed sclera.
- C. Shortness of breath.
- D. Light, frothy urine.
Correct Answer: B
Rationale: The icteric phase involves jaundice, causing yellowed sclera (B) due to bilirubin buildup. Tarry stools (A) indicate bleeding, not typical. Shortness of breath (C) and frothy urine (D) are unrelated.
The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations should the nurse include in the client's teaching plan? Select all that apply.
- A. Hearing loss.
- B. Visual disturbance.
- C. Headache.
- D. Orthopnea.
- E. Gout.
- F. Weight loss.
Correct Answer: B,C,D,E
Rationale: Polycythemia vera increases blood viscosity and red cell mass, leading to complications like visual disturbances (due to retinal hemorrhage), headaches (from hypertension or thrombosis), orthopnea (from heart failure), and gout (from increased uric acid due to cell turnover). Hearing loss and weight loss are not typical complications.