Nokea
The nurse is assessing a client with a suspected pulmonary embolism. Which of the following symptoms is most likely to be present?
- A. Bradycardia.
- B. Sudden chest pain.
- C. Hypotension.
- D. Fever.
Correct Answer: B
Rationale: Sudden chest pain is a common symptom of pulmonary embolism due to impaired blood flow to the lungs.
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The doctor orders a midstream urine specimen for your client who is an alert, oriented and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen?
- A. The need to cleanse the perineal area with circular wipes.
- B. The need to cleanse the perineal area from the 'dirtiest' to the 'cleanest'.
- C. The need to use a new antiseptic wipe for each wipe from the inner to the outer labia.
- D. The need to use a new antiseptic wipe for each wipe from the outer to the inner labia.
Correct Answer: C
Rationale: For a midstream urine specimen, the perineal area should be cleansed from front to back (inner to outer labia) using a new antiseptic wipe for each stroke to prevent contamination.
A 20-year-old single parent brings her 3-year-old son into the emergency department because he 'fell.' The child has bruises on his face, arms, and legs; his mother says that she did not witness the fall. The nurse suspects child abuse. While examining the child, the mother says, 'Sometimes I guess I'm pretty rough with him. I'm alone, and I just don't know how to manage him.' The nurse should ask the mother if she would find it helpful to have a referral to:
- A. A program for single parents.
- B. A parenting education program.
- C. A women's support group.
- D. A support group for abusive parents.
Correct Answer: B
Rationale: A parenting education program would provide the mother with skills to manage her child's behavior appropriately, addressing potential abuse triggers and improving parenting techniques.
An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. The nurse should advise the mother to do which of the following?
- A. Notify the physician immediately to adjust the treatment plan.
- B. Confine the infant to one room in the apartment.
- C. Keep the infant in the splint at night, removing it during the day.
- D. Remove any unsafe items from the area in which the infant is mobile.
Correct Answer: D
Rationale: Removing unsafe items ensures the infant's safety while mobile in a splint, preventing further injury. The other options are unnecessary or impractical.
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
- A. Loosen the bed restraints so the client can sit up.
- B. Raise the side rails to full upright position.
- C. Assess the client to determine why she wants to sit up.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: The nurse should fi rst determine why the client wants to sit up, and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising theside rails and elevating the head of the bed do not address the client’s needs.
A client has undergone a mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast when which behavior is observed?
- A. Refuses to look at the dressing
- B. Requires help with sponge bathing
- C. Asks that the nurse limit visitors to only family
- D. Dresses in a loose nightgown the client brought from home
Correct Answer: A
Rationale: The client demonstrates the most difficult adjustment to the loss if she refuses to look at the dressing. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery. Requiring help with sponge bathing is expected after major surgery, limiting visitors is also an expected behavior soon after surgery, and dressing in her own nightgown indicates that the client is retaining her self-esteem.