Nokea
The nurse is caring for a client admitted with congestive heart failure. Which finding would the nurse expect if the failure was on the right side of the heart?
- A. Jugular vein distention
- B. Dry, nonproductive cough
- C. Orthopnea
- D. Crackles on chest auscultation
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, leading to jugular vein distention, a hallmark sign of impaired right heart function.
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A client diagnosed with lung cancer asks the nurse what the term MO refers to. The nurse says that MO means
- A. no distant metastasis present.
- B. distant metastasis present.
- C. distant metastasis cannot be evaluated.
- D. metastasis present only in immediate lymph nodes.
Correct Answer: A
Rationale: In cancer staging, M0 indicates no distant metastasis, per TNM classification.
A client scheduled for a carotid endarterectomy requires insertion of an intra-arterial blood pressure-monitoring device. The nurse plans to perform the Allen test. Which observation indicates patency of the ulnar artery?
- A. Blanching of the hand on compression and release of the ulnar artery
- B. Muscular twitching of the bicep muscle with use of a tourniquet at the wrist
- C. Hand turning pink after the nurse releases the pressure on the ulnar artery
- D. Flexion of the wrist when tapping the ulnar artery with a reflex hammer
Correct Answer: C
Rationale: The Allen test assesses collateral circulation. The hand turning pink after releasing ulnar artery pressure indicates patency, ensuring adequate blood flow if the radial artery is cannulated.
A client undergoing 'cold-turkey' withdrawal from years of substance abuse is most at risk of serious life-threatening complications with which of the following substances?
- A. Heroin.
- B. Cocaine.
- C. Alcohol.
- D. Marijuana.
Correct Answer: C
Rationale: Alcohol withdrawal (C) can cause life-threatening complications like seizures and delirium tremens. Heroin (A), cocaine (B), and marijuana (D) withdrawal, while uncomfortable, are less likely to be fatal.
A home health nurse visits a 7-year-old boy on neutropenic precautions. His mother cares for him during the day. Which of the following statements by the mother indicates a need for further teaching?
- A. I will call the doctor if my son has a temperature above 38°C.'
- B. My son should protect his skin by showering every other day instead of daily.'
- C. His aunt cannot visit until 3 weeks have passed since her flu shot.'
- D. I will need to throw out the flowers he got as a get-well gift.'
Correct Answer: C
Rationale: Live vaccines (e.g., nasal flu vaccine) require a 3-week wait, but the standard flu shot is inactivated, posing no risk. The other statements are correct for neutropenic precautions.
A client with obsessive compulsive personality disorder annoys his coworkers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
- A. Helping the client develop a plan for changing his behavior
- B. Contracting with him for the time he spends on a task
- C. Avoiding a discussion of his annoying behavior because it will only make him worse
- D. Encouraging him to set a time schedule and deadlines for himself
Correct Answer: D
Rationale: Setting a time schedule helps the client manage perfectionistic tendencies by structuring tasks, reducing preoccupation with trivial details.