Nokea
The nurse identifies the type of presentation shown in the fi gure as which of the following?
- A. Frank breech.
- B. Compound breech.
- C. Complete breech.
- D. Incomplete breech.
Correct Answer: C
Rationale: For a complete breech, the buttocks present, the feet and legs are fl exed on the thighs, and the thighs are fl exed on the abdomen. For a frank breech, the buttocks present with the hips fl exed and the legs extended against the abdomen and chest. This is the most common type of breech presentation. For a compound breech, the buttocks present together with another part, such as a hand. This is a rare occurrence. For an incomplete breech, one or both feet or the knees extend below the buttocks. This can also be termed a single footling or double footling breech.
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A client with a history of heart failure is prescribed spironolactone (Aldactone). Which electrolyte imbalance should the nurse monitor for?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring to prevent arrhythmias.
You are caring for an acute care adult client in the medical unit who has no history of a psychiatric mental health disorder. This 76 year old client has suddenly and abruptly started to exhibit episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity. The client reports to you that they are seeing clowns in their room. This client is dehydrated and has just begun taking an anticholinergic medication. Which of the following is the most appropriate nursing diagnosis for this client?
- A. Psychotic symptoms related to sensory overload
- B. Psychotic symptoms related to a previously undiagnosed psychosis
- C. Visual disturbances related to dementia
- D. Visual disturbances related to delirium
Correct Answer: D
Rationale: The sudden onset of impaired cognition, fluctuating mental status, and visual hallucinations in the context of dehydration and anticholinergic medication use strongly suggests delirium, not dementia or psychosis.
A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, 'All this work with her has been useless. She's just going back to him as usual.' Which of the following statements by a nursing colleague would be most helpful to this nurse?
- A. Her reasons for staying are complex. She can leave only when she is ready and can be safe.'
- B. I know it is frustrating to work with clients who don't follow our advice.'
- C. I need to do you have her again and have another chance.'
- D. These women almost never leave for good because of their emotional and financial dependency.'
Correct Answer: A
Rationale: The colleague needs to provide the nurse with information about spouse abuse. Giving information about reasons for staying is useful for decreasing the nurse's frustration. Although expressing empathy is appropriate, it does not help the nurse understand the client's needs and behaviors. Telling the nurse that there will be another chance is not helpful and fails to educate the other nurse about the dynamics of abuse. Although dependence is a problem, women who are abused can overcome this and leave if they have support, not criticism.
Which of the following should the nurse do first for a toddler just admitted with croup?
- A. Monitor vital signs
- B. Assess respiratory status
- C. Ensure adequate fluid intake
- D. Place a tracheostomy set at the bedside
Correct Answer: B
Rationale: Assessing respiratory status is the priority for a toddler with croup, as airway obstruction is a primary concern. Vital signs, fluids, and tracheostomy preparation are secondary.
A client who is recovering from transurethral resection of the prostate (TURP) experiences urinary incontinence. He tells the nurse that he has decreased his fluid intake because of the incontinence. What would be the nurse's best response to the client?
- A. Yes, limiting your fluids can decrease your incontinence.'
- B. Limiting your fluids will cause kidney stones.'
- C. I think eight glasses of water a day and urinate every 2 hours.'
- D. If your incontinence continues, we will reinsert your catheter.'
Correct Answer: C
Rationale: Encouraging adequate fluid intake (eight glasses) and scheduled voiding (every 2 hours) helps manage incontinence and maintain urinary health post-TURP.