Nokea
The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention?
- A. Place an indwelling urinary catheter and measure strict Intake and output.
- B. Initiate bilateral intermittent sequential pneumatic compression devices.
- C. Administer aspirin to prevent further det formation and platelet dumping.
- D. Obtain a focused history to determine recent bleeding and use of anticoagulants.
Correct Answer: D
Rationale: A focused history assesses for stroke risk factors like anticoagulant use, critical for managing neurological symptoms.
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Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Client describes a schedule for antacid use with other prescribed medications.
- B. Client selects a pattern of small meals alternating with fluid intake.
- C. Client expresses a willingness to reduce nicotine intake.
- D. Client agrees to participate in a variety of stress reduction techniques.
Correct Answer: B
Rationale: Small, frequent meals reduce rapid gastric emptying, addressing dumping syndrome symptoms post-Billroth II.
An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?
- A. What time of day the multivitamin is taken.
- B. The amount of calcium in the multivitamin.
- C. Usual activity after taking the multivitamin.
- D. If the multivitamin is taken with a meal or snack
Correct Answer: B
Rationale: Confirming calcium content in the multivitamin ensures adequate intake for bone health, critical for osteoporosis prevention.
A young adult client involved in a minor motor vehicle collision three weeks ago reports having a headache, blurred vision, vertigo, and nausea. The client's vital signs are within normal limits, and a nutrition history reveals that the client is eating very little because of being concerned about paying for car repairs. Priority nursing care should be based on which nursing problem?
- A. High risk for injury related to increased intracranial pressure.
- B. Alteration in comfort related to motor vehicle collision.
- C. Alteration in nutrition related to poor dietary intake.
- D. Anxiety related to unknown outcome of automobile repairs.
Correct Answer: A
Rationale: Symptoms suggest increased intracranial pressure, a serious post-collision complication, prioritizing over comfort or nutrition.
Nurses votes
Skin assessment reveals a stage 2 pressure injury on the right trochanter. Measures 0.79" x 1.57" x 0.39 (2 cm X 4 cm X 1 cm). Minimal drainage noted. Painful to touch. The Braden Scale was utilized during the skin assessment. The score is two for sensory, three for moisture, two for activity, two for mobility, two for nutrition and one for friction and shear.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Actions to Take
A. Begin enteral feedings
B. Insert Indwelling urinary catheter
C. Ambulate every four
D. Apply pressure reduction mattress to bed
E. Request service of wound care nurse
- B. Potential Conditions
Choices
A. Immobility
B. Dehydration
C. Malnutrition
D. Poor healing of stage 2 pressure injury
- C. Parameters to monitor
Choices
A. Sterile dressing changes
B. Adherence to repositioning schedule hours
C. Temperature
D. Laboratory studies for malnutrition status
E. Progression of wound
Correct Answer: D
Rationale: Poor healing of a pressure injury requires a pressure reduction mattress and wound care nurse consultation, monitoring wound progression and repositioning adherence.
While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?
- A. Appearance of the skin on the client's legs.
- B. Altered posture and balance during ambulation.
- C. Presence of bilateral femoral pulses.
- D. Signs of old and new ecchymosis.
Correct Answer: A
Rationale: Assessing skin appearance for signs of neuropathy supports hair loss as a diabetes complication.