Nokea
The nurse is caring for a client with a history of Cushing’s syndrome.
- A. Which symptom is expected in a client with Cushing’s syndrome?
- B. Weight loss and fatigue.
- C. Moon face and truncal obesity.
- D. Hypotension and bradycardia.
- E. Polyuria and thirst.
Correct Answer: B
Rationale: Moon face and truncal obesity result from cortisol excess in Cushing’s syndrome. Weight loss, hypotension, and polyuria are more typical of Addison’s disease or diabetes insipidus.
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Which nursing action is MOST appropriate after intubating a postoperative client who had a respiratory arrest?
- A. Soak the intubation equipment in concentrated Betadine solution.
- B. Place the intubation blade in a bag and arrange for gas sterilization.
- C. Soak the intubation blade in Cidex solution.
- D. Wash the equipment with soap and water and allow to air-dry.
Correct Answer: B
Rationale: Gas sterilization ensures intubation equipment is pathogen-free, critical after exposure to body fluids. Options A, C, and D are inadequate for sterilization.
The nurse is auscultating the chest of a client with heart failure. The nurse should assess for which finding as an early sign of volume overload?
- A. S3 heart sound
- B. Murmur
- C. S4 heart sound
- D. Hypoventilation
Correct Answer: A
Rationale: S3 heart sound. This is an early sign of volume overload due to fluid in the ventricles during diastole.
A client with stage-four Parkinson's disease.
In developing discharge plans with the family of the client with stage-four Parkinson's disease, it is MOST important for the nurse to include which of the following activities?
- A. Ambulate twice daily.
- B. ROM exercise to all extremities four times a day.
- C. Include activities such as knitting and putting puzzles together.
- D. Encourage and provide writing materials.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client would be unable to ambulate (2) correct-in stage four Parkinson's disease, client is immobile (3) client cannot perform activities that require small-muscle dexterity (4) client cannot perform activities that require small-muscle dexterity
A client suspected to have bulimia.
Which of the following observations by the nurse would MOST likely indicate bulimia?
- A. The client has edema of the lower extremities.
- B. Physical exam of the client reveals the presence of lanugo.
- C. The client has ulcerated mucous membranes of the mouth.
- D. The client has dry, yellowish color of the skin.
Correct Answer: C
Rationale: Strategy: Determine the cause of each symptom. Does it relate to bulimia? (1) common with anorexia (2) seen with anorexia (3) correct-due to frequent vomiting (4) bulimics are normal in appearance
A client preparing for surgery.
Which of the following statements by the client BEST indicates to the nurse an emotional readiness for surgery?
- A. I know the doctor isn't telling me everything, but at this point I can't do anything about it.'
- B. I've never heard of this specialist before. Does he do much work here?'
- C. I'm glad the trapeze is on my bed so I can start working on my exercises as soon as I wake up.'
- D. Can you please check my record to be sure it says I'm diabetic?'
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) indicates feelings of fear and helplessness (2) indicates fear and lack of trust (3) correct-indicates acceptance and a readiness to participate in postoperative care (4) indicates fear that something will be missed