Nokea
The nurse is assessing a client with a suspected spinal cord injury. Which of the following findings is most indicative of this condition?
- A. Loss of sensation below the injury site.
- B. Increased muscle tone in the arms.
- C. Normal bowel and bladder function.
- D. Absence of pain at the injury site.
Correct Answer: A
Rationale: Loss of sensation below the injury site is a hallmark sign of spinal cord injury due to disrupted nerve pathways.
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The nurse is teaching a client with hypertension about lifestyle modifications. Which of the following recommendations is most effective in reducing blood pressure?
- A. Increasing dietary potassium intake.
- B. Reducing daily sodium intake.
- C. Drinking one glass of red wine daily.
- D. Taking a daily multivitamin.
Correct Answer: B
Rationale: Reducing sodium intake is highly effective in lowering blood pressure by decreasing fluid retention and vascular resistance.
After teaching the parents of a toddler about appropriate snack foods for their child, the nurse judges that the instructions about not giving the child raisins for snacks are effective when the father states should be following?
- A. Raisins are low in nutritional value
- B. Raisins are easy to choke on
- C. Raisins can increase tooth decay
- D. Raisins are hard to digest entirely
Correct Answer: B
Rationale: Raisins are a choking hazard for toddlers due to their size and texture, making this the correct reason to avoid them. Nutritional value, tooth decay, and digestion are less relevant concerns.
Your client has presented in the emergency department with a sudden onset of shortness of breath, dysphagia, dyspnea, coughing, and pain in the chest, arms, neck, and back. Which of the following would you most likely suspect?
- A. Hypovolemic shock
- B. Septic shock
- C. A dissected thoracic aortic aneurysm
Correct Answer: C
Rationale: Sudden onset of these symptoms, especially chest and back pain, suggests a dissected thoracic aortic aneurysm, a life-threatening condition requiring urgent intervention.
A widowed client who is receiving chemotherapy tells the nurse that he does not like to cook for himself. A community resource for this client is:
- A. Hospice Association.
- B. Visiting Nurses' Association (VNA).
- C. Meals on Wheels.
- D. American Association of Retired Persons (AARP).
Correct Answer: C
Rationale: Meals on Wheels provides home-delivered meals, which directly addresses the client's difficulty with cooking. Hospice is for end-of-life care, VNA focuses on nursing services, and AARP offers advocacy, not meal services.
The nurse is evaluating a weight-reduction plan designed for an obese client. Which statement by the client indicates the need for further teaching?
- A. It is so difficult to find food exchanges that taste good and fill me up.
- B. This diet doesn't let me go out for lunch with my friends at work anymore.
- C. I wish my mother could have seen me lose the 60 pounds in the last 9 months.
- D. My wife was kidding me the other night about my being a whole new husband.
Correct Answer: B
Rationale: Option 2 indicates that the client may be having difficulty in making appropriate dietary choices when going out for lunch or that he may perceive that his coworkers are uncomfortable with his need to eat differently. A sense of not fitting in can leave the obese individual isolated and therefore make it more difficult for him to maintain his diet at work. In the absence of other data, option 1 is a normal response to the changes in eating habits. Options 3 and 4 are responses indicating a positive perception of self; that is, another person has recognized these changes, and the client wishes to have been able to share these changes with his mother.