Nokea
The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
- A. “Is there anything that you are stressed about right now that I should know?”
- B. “What reasons do you think are contributing to your fatigue?”
- C. “What are your normal work hours?”
- D. “Are you sleeping 8 hours a night?”
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to reflect on their own thoughts and identify potential causes of their fatigue. It allows the patient to express their own insights and helps the nurse understand the underlying reasons for the fatigue. Choice A focuses on stress, which may not be the main cause of fatigue. Choice C is irrelevant to exploring the fatigue further. Choice D assumes that lack of sleep is the main issue, which may not be the case for the patient.
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Why would a Heimlich maneuver be performed on a client?
- A. To increase the absorption of the prescribed medication
- B. To clear the airway if the client cannot speak or breathe after swallowing food
- C. To reduce the potential for injuries as a result of falls
- D. To maintain extremities in proper anatomic position CARING FOR CLIENT WITH HEAD AND SPINAL CORD TRAUMA
Correct Answer: B
Rationale: The Heimlich maneuver is performed to clear the airway if a client is choking and cannot speak or breathe after swallowing food. Step 1: Assess the situation and confirm airway obstruction. Step 2: Stand behind the client, wrap your arms around their waist, and deliver upward abdominal thrusts. Step 3: Repeat thrusts until the object is dislodged. Other choices are incorrect as they do not address airway obstruction. A: Increasing medication absorption is not a purpose of the Heimlich maneuver. C: Preventing falls and D: Maintaining extremities in proper position are not related to choking emergencies.
For which of the following problems should the nurse monitor in the patient with multiple myeloma?
- A. Uncontrolled bleeding
- B. Liver engorgement
- C. Respiratory distress
- D. Pathological fractures
Correct Answer: D
Rationale: The correct answer is D: Pathological fractures. In multiple myeloma, abnormal plasma cells can weaken the bones, leading to fractures even with minimal trauma. The nurse should monitor for signs of bone pain, decreased mobility, and pathological fractures to prevent complications.
Uncontrolled bleeding (A) is not typically associated with multiple myeloma. Liver engorgement (B) is more commonly seen in conditions like congestive heart failure or liver disease. Respiratory distress (C) is not a common manifestation of multiple myeloma.
Therefore, the nurse should focus on monitoring for pathological fractures as a priority in a patient with multiple myeloma.
A guest who is diabetic attended a bridal affair. The guest started to tremble and started to feel dizzy. Luckily a nurse is present. The best action for the nurse to take is to:
- A. encourages the guest to eat some
- B. call the guest’s personal hygiene
- C. offer the guest a peppermint
- D. give the guest a glass of orange juice
Correct Answer: D
Rationale: The correct answer is D: give the guest a glass of orange juice. This is the best action because the guest is likely experiencing hypoglycemia due to being diabetic. Orange juice contains fast-acting sugar that can quickly raise blood sugar levels. Encouraging the guest to eat some (choice A) may take longer to have an effect. Calling the guest's personal hygiene (choice B) is irrelevant to the situation. Offering the guest a peppermint (choice C) will not effectively raise blood sugar levels.
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
- A. Lungs
- B. Liver
- C. Kidneys
- D. Heart
Correct Answer: D
Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications.
Summary:
A: Lungs - Not directly affected by potassium levels.
B: Liver - Not directly affected by potassium levels.
C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Mammography
- C. Fine needle aspiration
- D. Chest x-ray
Correct Answer: C
Rationale: The correct answer is C: Fine needle aspiration. This procedure involves inserting a thin needle into the lump to extract cells for examination. It provides a definitive diagnosis of breast cancer by analyzing the cells for cancerous features. Breast self-examination (A) is a screening tool but cannot confirm a diagnosis. Mammography (B) is used for screening and detecting abnormalities but also requires further testing for diagnosis. Chest x-ray (D) is not used to diagnose breast cancer.