Nokea
The nurse is caring for a client who has just had a mastectomy. Which exercise should the nurse assist the client in doing during the first 24 hours after surgery?
- A. Hand wall climbing
- B. Pendulum arm swings
- C. Elbow flexion and extension
- D. Shoulder abduction and external rotation
Correct Answer: C
Rationale: During the first 24 hours after surgery, the client is assisted to move the fingers and hands, and to flex and extend the elbow. The client may also use the arm for self-care provided that she does not raise the arm above shoulder level or abduct the shoulder. The exercises identified in the remaining options are done once surgical drains are removed and wound healing is well established.
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A client is being treated for acute low back pain. Which of these clinical manifestations must be reported to the physician immediately?
- A. Diffuse, aching sensation in the L4 to L5 area
- B. New onset of footdrop
- C. Pain in the lower back when the leg is lifted
- D. Pain in the lower back that radiates to the hip
Correct Answer: B
Rationale: New onset footdrop indicates possible nerve compression or damage, requiring immediate reporting to prevent permanent impairment. Other symptoms are common in low back pain and less urgent.
A client with a history of cirrhosis is prescribed propranolol (Inderal). The nurse should monitor the client for which of the following therapeutic effects?
- A. Decreased portal hypertension.
- B. Increased blood glucose.
- C. Decreased ammonia levels.
- D. Increased platelet count.
Correct Answer: A
Rationale: Propranolol reduces portal hypertension by decreasing portal vein pressure in cirrhosis.
A client with a history of peptic ulcer disease is prescribed sucralfate (Carafate). The nurse should instruct the client to:
- A. Take the medication 1 hour before meals.
- B. Take the medication with meals.
- C. Take the medication at bedtime.
- D. Stop the medication if constipation occurs.
Correct Answer: A
Rationale: Sucralfate should be taken 1 hour before meals to coat the stomach lining and protect ulcers.
A nurse notices that a newborn has a swelling in the scrotum. The nurse should interpret this as indicative of hydrocele if which of the following occurs?
- A. The swollen bulge can be reduced.
- B. The increase in scrotal size is bilateral.
- C. The scrotal sac can be transilluminated.
- D. The bulge appears during crying.
Correct Answer: C
Rationale: Transillumination of the scrotal sac indicates fluid, characteristic of a hydrocele, a common newborn condition.
A family has taken home their newborn and later received a call from the pediatrician that the PKU levels for their newborn daughter are abnormally high. Additional testing confirmed the diagnosis of phenylketonuria. The parents refuse to believe the results as no one else in their family has the disease. The nurse explains that the disease:
- A. Is carried on recessive genes contributed by each parent.
- B. Is caused by a recessive gene contributed by either parent.
- C. Is cured by eliminating dietary protein for this child.
- D. Will not impact future childbearing for the family.
Correct Answer: A
Rationale: Phenylketonuria is an autosomal recessive disorder, requiring both parents to contribute a defective gene. It is not caused by a single parent's gene, cannot be cured by diet alone (though managed by low-phenylalanine diet), and may impact future childbearing as parents are carriers.