Nokea
The nurse is assessing the client's abdomen. Which should the nurse do first?
- A. Auscultate
- B. Percuss
- C. Inspect
- D. Palpate
Correct Answer: C
Rationale: Abdominal assessment begins with inspection to observe for visible abnormalities, followed by auscultation, percussion, and palpation to avoid altering bowel sounds.
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An adult woman is admitted to an acute locked psychiatric unit one month prior to an election.
Which of the following responses by the nurse is BEST?
- A. You are not eligible to vote because you are a psychiatric patient.'
- B. I'll make the appropriate arrangements for you to vote.'
- C. You may vote only if you are discharged by Election Day.'
- D. I'll contact the Election Board to see if you are registered to vote.'
Correct Answer: B
Rationale: Strategy: Determine the outcome of each answer choice. (1) psychiatric patients do not forfeit their constitutional rights (2) correct-patient can vote by absentee ballot (3) can vote by absentee ballot (4) not the nurse's responsibility
A school-aged child who was diagnosed two weeks ago with hepatitis A.
Which of the following responses by the nurse is BEST?
- A. You must isolate your child at home for two more weeks.
- B. Why don't you speak with the physician about this matter?
- C. Your child may return to school this week.
- D. Your child may return to school in 2 weeks but cannot participate in sports.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) communicable for 2-3 weeks before onset of jaundice and about 1 week after onset of jaundice (2) passing the buck (3) correct-type A hepatitis is not infectious within a week or so after the onset of jaundice, child can return to school (4) can return to school, activity at that time depends on the child's energy level
The nurse is caring for a client with a history of polycystic kidney disease.
- A. Which symptom is expected in a client with polycystic kidney disease?
- B. Chest pain and dyspnea.
- C. Flank pain and hematuria.
- D. Weight loss and fever.
- E. Numbness in the extremities.
Correct Answer: B
Rationale: Flank pain and hematuria are common in polycystic kidney disease due to cyst pressure and rupture. Chest pain, weight loss, and numbness are unrelated.
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
- A. Check pedal pulses.
- B. Check legs for pitting edema.
- C. Upper extremity neuro checks.
- D. Auscultate lung sounds.
- E. Observe respirations.
- F. Observe for gait disturbances.
Correct Answer: B,D,E
Rationale: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
A mother brings her two-year-old boy to the pediatrician’s office.
- A. Which symptom would suggest to the nurse that a two-year-old boy has strabismus?
- B. When the child draws, he places his head close to the table.
- C. The child rubs his eyes frequently.
- D. The child closes one eye to see a poster on the wall.
- E. The child is unable to see objects in the periphery of his visual field.
Correct Answer: C
Rationale: Strabismus is characterized by misaligned visual axes, causing the brain to receive two images. Closing one eye to focus on an object, such as a poster, is a compensatory behavior indicative of strabismus. The other symptoms suggest refractive errors or other visual impairments, not strabismus.