Nokea
The nurse is assessing a client with suspected dehydration. Which finding supports this diagnosis?
- A. Bounding pulse.
- B. Dry mucous membranes.
- C. Hypertension.
- D. Increased urine output.
Correct Answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration due to reduced fluid volume in the body.
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A client who had transurethral resection of the prostate complains of dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had $200 \mathrm{~mL}$ of urine output in the last 8 hours with a $1,000 \mathrm{~mL}$ intake. Which of the following interventions is a priority for the nurse at this time?
- A. Apply a condom catheter
- B. Assess for bladder distention
- C. Obtain a urine specimen for culture
- D. Teach the client Kegel exercises
Correct Answer: B
Rationale: Low urine output and dribbling post-TURP suggest possible bladder distention, which requires immediate assessment to prevent complications. Other interventions may follow based on findings.
A client has been diagnosed with Bell's palsy. The nurse assesses the client to determine if which signs/symptoms are present?
- A. Eye paralysis and ptosis of the eyelids
- B. Chewing difficulties and one-sided facial droop
- C. Fixed pupil and an elevated eyelid on one side
- D. Twitching of one side of the face and ruddy cheeks
Correct Answer: B
Rationale: Bell's palsy is a one-sided facial paralysis resulting from compression of the facial nerve (CN VII). There is facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and chewing difficulties. The other items listed are not associated with this disorder.
The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful?
- A. Place bedside articles on the left side.
- B. Approach the client from the right side.
- C. Teach the client to scan the environment.
- D. Move the commode and chair to the left side.
Correct Answer: B
Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well.
The nurse is teaching a 17-year-old girl who has a severe gonorrheal infection. The nurse realizes that the girl needs further teaching when she states:
- A. Once I'm treated, I'll have immunity.'
- B. My partner doesn't need treatment.'
- C. I won't have any more problems once I learn to protect myself.'
- D. I could have trouble getting pregnant.'
Correct Answer: A,B
Rationale: Gonorrhea does not confer immunity, and partners require treatment to prevent reinfection. Potential infertility is a correct understanding, but believing protection eliminates all problems is overly optimistic.
The mother of a 7-month-old child born 6 weeks early asks the nurse what play activities and toys are appropriate for her child. Which of the following should the nurse suggest?
- A. Picture books
- B. Peek-a-boo
- C. Rattle
- D. Colored blocks
Correct Answer: B
Rationale: Peek-a-boo is an age-appropriate activity for a 7-month-old, promoting social and cognitive development. Picture books and colored blocks are better for older children, and a rattle may be less engaging for this age.