Nokea
The nurse is assessing a client with a suspected bowel obstruction. Which of the following findings is most indicative of this condition?
- A. Abdominal distension.
- B. Decreased bowel sounds.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A,B
Rationale: Abdominal distension and decreased bowel sounds are hallmark signs of bowel obstruction due to blocked intestinal passage.
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You are the nursing supervisor in a long term care facility. One of the major considerations that you apply into your practice is strict infection control prevention measures because you are knowledgeable about the fact that the normal aging process is associated with the deterioration of the body's normal defenses. Which theory of aging supports your belief that strict infection control prevention measures are necessary?
- A. The Programmed Longevity Theory
- B. The Immunological Theory of Aging
- C. The Endocrine Theory
- D. The Rate of Living Theory
Correct Answer: B
Rationale: The Immunological Theory of Aging posits that the immune system weakens with age, increasing susceptibility to infections. This supports the need for strict infection control measures in a long-term care facility.
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.
Which of the following are the five Rights of Supervision?
- A. The right task, the right circumstances, the right person, the right competency, and the right supervision or feedback
- B. The right task, the right circumstances, the right person, the right direction or communication, and the right supervision or feedback
- C. The right competency, the right education and training, the right scope of practice, the right environment and the right client condition
- D. The right competency, the right person, the right scope of practice, the right environment and the right client condition
Correct Answer: B
Rationale: The five Rights of Supervision are the right task, right circumstances, right person, right direction or communication, and right supervision or feedback . These ensure that delegated tasks are performed safely and effectively by the appropriate personnel under proper guidance.
A college student is asking the nurse about his grandfather, who just received a diagnosis of Huntington's disease. The student wants to know if he will have the disease, too. What should the nurse tell the student? Select all that apply.
- A. Huntington's disease affects men more than women.'
- B. Huntington's disease is an autosomal dominant disease.'
- C. Huntington's disease does not skip a generation.'
- D. Huntington's disease is a treatable disease.'
- E. There is a 75% chance you will have the disease.'
Correct Answer: B,C
Rationale: Huntington's disease is an autosomal dominant disorder, meaning a 50% chance of inheritance if one parent is affected, and it typically does not skip generations. It affects men and women equally, is not treatable (only symptom management is available), and the risk is not 75% but 50%.
The nurse is teaching a client about the modifiable risk factors that can reduce the risk for colorectal cancer. The nurse places priority on discussing which risk factor with this client?
- A. Age older than 30 years
- B. High-fat and low-fiber diet
- C. Distant relative with colorectal cancer
- D. Personal history of ulcerative colitis or gastrointestinal polyps
Correct Answer: B
Rationale: Clients should be aware of modifiable risk factors as part of general health maintenance and primary disease prevention. Modifiable risk factors are those that can be reduced and include a high-fat and low-fiber diet. Common risk factors for colorectal cancer that cannot be changed include age older than 40 years, first-degree relative with colorectal cancer, and history of bowel problems such as ulcerative colitis or familial polyposis.