Nokea
The nurse explains to the client with pain that the purpose of biofeedback is to enable him to exert control over his physiologic processes by:
- A. Regulating the body processes through electrical control.
- B. Shocking himself when an undesirable response is elicited.
- C. Monitoring the body processes for the therapist to interpret.
- D. Translating the signals of his body processes into observable forms.
Correct Answer: D
Rationale: Biofeedback translates physiological signals (e.g., heart rate) into observable forms, allowing the client to control them consciously. It does not involve electrical shocks, therapist interpretation, or direct electrical regulation.
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The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The client understands the discharge plan when the client:
- A. Selects a low-cholesterol diet to control coronary artery disease.
- B. States a need for bed rest for 1 week after discharge.
- C. Verbalizes safety precautions needed to prevent pacemaker malfunction.
- D. Explains signs and symptoms of myocardial infarction (MI).
Correct Answer: C
Rationale: Understanding safety precautions (e.g., avoiding strong electromagnetic fields) prevents pacemaker malfunction, indicating discharge plan comprehension.
Which of the following is a late symptom of polycythemia vera?
- A. Headache.
- B. Dizziness.
- C. Pruritus.
- D. Shortness of breath.
Correct Answer: C
Rationale: Pruritus, especially after warm baths, is a late symptom of polycythemia vera due to increased histamine release from elevated basophils. Headache, dizziness, and shortness of breath are earlier symptoms related to increased blood viscosity and hypermetabolism.
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: Fluid sequestration into the retroperitoneal space (B) causes significant hypovolemia in pancreatitis, complicating shock management. Intestinal hemorrhage (A), infection (C), and cardiac output (D) are secondary or less common contributors.
Which of the following increases the risk of having a large abdominal aortic aneurysm rupture?
- A. Anemia
- B. Dehydration
- C. High blood pressure
- D. Hyperglycemia
Correct Answer: C
Rationale: High blood pressure increases wall stress in a large abdominal aortic aneurysm, elevating the risk of rupture per Laplace's law (wall tension ˆ pressure × radius). Anemia, dehydration, and hyperglycemia do not directly increase rupture risk.
The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the client's postoperative status?
- A. Radial pulse
- B. Pedal pulse
- C. Brachial pulse
- D. Popliteal pulse
Correct Answer: B
Rationale: Assessing the pedal pulse post-femoral-popliteal bypass is most accurate for evaluating graft patency and distal perfusion. A palpable or Doppler-detected pedal pulse indicates successful restoration of blood flow to the lower extremity. Other pulses (radial, brachial, popliteal) are less specific to the surgical site.