Nokea
The nurse is caring for a client receiving treatment for hypoparathyroidism. The nurse determines that treatment has been successful if which of the following was observed?
- A. The client's output is 1500 cc of clear straw-colored urine.
- B. The client is unable to state his name.
- C. The client denies numbness and tingling.
- D. The client loses 3 pounds in one week.
Correct Answer: C
Rationale: Hypoparathyroidism causes hypocalcemia, leading to numbness and tingling. Their absence indicates successful calcium therapy. Options A, B, and D are unrelated or indicate other issues.
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Which of the following nursing observations documented in the client's chart MOST clearly indicates the client's mood?
- A. Client states, 'I see snakes climbing on the walls at all times of the day.'
- B. Unable to sustain a train of thought for long periods of time during history-taking.
- C. Clenches her fists and shouts in an angry tone of voice when asked about family problems.
- D. Is unaware of where she is, what day and year it is, or what time it is.
Correct Answer: C
Rationale: gives data that reflect client's feelings, tone, and behavior associated with those feelings, as well as content area of conversation that evoked that mood
While a two-day-old infant is in surgery for repair of spina bifida, the infant's mother expresses concern to the nurse because the doctor told her the infant would be confined to a wheelchair. Which of the following statements, if made by the nurse, is BEST?
- A. Physical therapy can restore the function to affected muscles.
- B. Orthopedic devices will allow your child to strengthen lower extremity muscles.
- C. Corrective surgery will return function to the affected muscles.
- D. The corrective surgery will not change your child's physical disability.
Correct Answer: D
Rationale: spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele
Which of the following activities documented by the recreational therapist following a community reorientation outing for a paraplegic client would indicate to the nurse a readiness for discharge?
- A. The client states that he/she enjoyed being outside the hospital environment.
- B. The client was able to participate in a structured team sport by keeping score.
- C. The client was independently able to order his meal and feed himself.
- D. The client was independent in transfers and wheelchair mobility.
Correct Answer: D
Rationale: correct, physical, these skills are requisite for discharge
A patient complains of pain after an appendectomy. After administering an analgesic, the nurse should take which of the following actions?
- A. Elevate the head of the bed 30-45°.
- B. Place a pillow behind the patient's knees.
- C. Elevate the knee gatch on the bed 30°.
- D. Lie the client supine with a small pillow under the head.
Correct Answer: A
Rationale: would reduce stress on suture line and provide for comfort
The nursing staff is planning to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program?
- A. Monitor the client's ability to complete her activities of daily living (ADL).
- B. Assess the client's levels of pain and correlate it with her response to analgesia.
- C. Observe the client's behavior at regular intervals to obtain baseline information related to her screaming.
- D. Ask the client why she is screaming and document it on her nursing assessment record.
Correct Answer: C
Rationale: to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors