Nokea
The nurse is assisting the physician with the insertion of a central venous catheter. Which statement best explains the rationale for placing the client in Trendelenburg position?
- A. It will make catheter insertion easier.
- B. It will make the client more comfortable.
- C. It will prevent ventricular tachycardia.
- D. It will prevent the development of pulmonary emboli.
Correct Answer: A
Rationale: Trendelenburg position elevates the veins, making central venous catheter insertion easier. Comfort , tachycardia , and emboli are not primary concerns.
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A client with a family history of Huntington's disease asks the nurse for information on how the disease is transmitted. Which of the following statements indicates that she understands the nurse's teaching?
- A. The chances of my passing the disease to my child are 1 in 2
- B. I have no chance of passing the disease to a male child, but a female child would carry the disease
- C. I have no chance of passing the disease to a female child, but a male child will have the disease
- D. The chances of my passing the disease to my child are 1 in 4
Correct Answer: A
Rationale: Huntington's disease is autosomal dominant, meaning there is a 50% (1 in 2) chance of passing the gene to each child, regardless of sex.
A transfer truck carrying toxic chemicals derails, spilling the contents and emitting toxic fumes over several miles. As a result, many of the area residents complain of nausea, vomiting, and headache. According to the agent-host model, the host is:
- A. The train carrying the toxic chemicals
- B. Toxic fumes emitted by the derailed box cars
- C. Physical problems experienced by the residents
- D. The residents living in the area
Correct Answer: D
Rationale: In the agent-host model, the host is the affected individual (residents). The toxic fumes are the agent, and symptoms are the outcome.
A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include
- A. explaining that the client will be walking with a prosthesis soon after surgery.
- B. encouraging the client to share his feelings and fears about the surgery.
- C. taking the informed consent form to the client and asking him to sign it.
- D. evaluating how the client plans to maintain his schoolwork during hospitalization.
Correct Answer: B
Rationale: discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
- A. Altered nutrition: less than body requirements
- B. Potential complication hemorrhage
- C. Ineffective individual coping
- D. Fluid volume excess
Correct Answer: B
Rationale: Potential complication hemorrhage. Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
Which assessment finding is most indicative of increased ICP in a client admitted with a basilar skull fracture?
- A. Nausea and vomiting
- B. Headache
- C. Dizziness
- D. Papilledema
Correct Answer: D
Rationale: Papilledema, or swelling of the optic disc, is a specific sign of increased intracranial pressure due to pressure on the optic nerve. Nausea, vomiting, headache, and dizziness are less specific symptoms, so answers A, B, and C are incorrect.