Nokea
The nurse is caring for a client with a history of ulcerative colitis. The nurse should expect the client to have:
- A. Bloody diarrhea
- B. Constipation
- C. Epigastric pain
- D. Weight gain
Correct Answer: A
Rationale: Ulcerative colitis causes mucosal inflammation, leading to bloody diarrhea, a hallmark symptom.
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A client requires log rolling after back surgery. Correctly provide the sequence of steps the nurse should follow when performing the procedure.
- A. Obtain assistance; three nurses are preferable.
- B. Maintain client's position in alignment with pillows.
- C. Position two nurses on the side the client will be turned to and the third nurse on the opposite side of the bed.
- D. Designate the person at the head of the bed to be in charge of coordinating the move.
- E. Place a pillow between the client's knees.
- F. Move the client in one coordinated movement when the nurse at the head of the bed signals to move the client.
- G. Instruct the client to place the arms across the chest.
Correct Answer: A, C, D, G, E, B, F
Rationale: Log rolling sequence: Obtain assistance (A), position nurses (C), designate leader (D), instruct arm placement (G), place pillow (E), align with pillows (B), move coordinately (F).
The nurse is caring for a client with a diagnosis of placenta accreta. Which intervention is most appropriate?
- A. Prepare for possible hysterectomy
- B. Administer tocolytics
- C. Monitor fetal heart tones
- D. Administer antibiotics
Correct Answer: A
Rationale: Placenta accreta often prevents placental separation leading to severe hemorrhage during delivery which may necessitate hysterectomy. Tocolytics fetal monitoring and antibiotics are not primary interventions for this condition.
Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?
- A. Distant breath sounds
- B. Increased heart sounds
- C. Decreased anteroposterior chest diameter
- D. Collapsed neck veins
Correct Answer: A
Rationale: Distant breath sounds are characteristic of emphysema due to increased anteroposterior chest diameter, overdistention, and air trapping.
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Increased anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (A) and anxiety (C) are common in both, and normal temperature (D) is nonspecific.
In preparation for the removal of the client's chest tubes, the nurse should instruct the client to:
- A. Breathe normally
- B. Hold his breath and bear down
- C. Take deep breaths
- D. Take shallow breaths
Correct Answer: B
Rationale: During chest tube removal, the client should hold their breath and bear down (Valsalva maneuver) to increase intrathoracic pressure, reducing the risk of air entering the pleural space.