Nokea
The nurse is caring for a client with a suspected tension pneumothorax. Which finding requires immediate action?
- A. Tracheal deviation
- B. Mild dyspnea
- C. Oxygen saturation of 92%
- D. Subcutaneous emphysema
Correct Answer: A
Rationale: Tracheal deviation is a life-threatening sign of tension pneumothorax, indicating mediastinal shift and requiring immediate decompression.
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A client with Parkinson's disease is prescribed levodopa-carbidopa (Sinemet). The nurse should instruct the client to:
- A. Take the medication on an empty stomach.
- B. Avoid vitamin B6 supplements.
- C. Take the medication with a high-protein meal.
- D. Stop the medication if dizziness occurs.
Correct Answer: B
Rationale: Vitamin B6 can reduce the effectiveness of levodopa, so clients should avoid B6 supplements.
Intussusception occurs when:
- A. Part of the intestine slides into another part of the intestine.
- B. The appendix ruptures.
- C. An ileostomy stoma retracts below the abdominal surface.
- D. Lungs are infiltrated.
Correct Answer: A
Rationale: Intussusception is a condition where one segment of the intestine telescopes into another, causing obstruction, most commonly in children.
The nurse should plan to teach a client who is taking warfarin sodium (Coumadin) to do which of the following?
- A. Consult the physician before undergoing dental work.
- B. Avoid the use of a toothbrush during oral hygiene.
- C. Use rectal suppositories to treat constipation.
- D. Eat green leafy vegetables.
Correct Answer: A
Rationale: Warfarin increases bleeding risk, so consulting a physician before dental work is essential to manage anticoagulation.
You are running a caregiver support group for those who are caring for a person with impaired cognition related to Alzheimer's disease. You are planning a session on the stages of Alzheimer's disease, its progression and some useful helpful tips for these participating care givers. Which of the following elements should you include in this session?
- A. According to the Global Deterioration Scale, clients in the first stage of Alzheimer's disease tend to cover up their failing abilities
- B. According to the Reisberg Scale, clients in the first stage of Alzheimer's disease tend to cover up their failing abilities
- C. According to the Global Deterioration Scale, clients in the third stage of Alzheimer's disease tend to cover up their failing abilities
- D. According to the Reisberg Scale, clients in the fourth stage of Alzheimer's disease tend to cover up their failing abilities
Correct Answer: B
Rationale: The Reisberg Scale (Global Deterioration Scale) indicates that in the first stage, individuals with Alzheimer's may cover up their failing abilities, which is an important point to include for caregivers to understand early disease behaviors.
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
- A. Place the client in a wheelchair to protect their safety in the clinic.
- B. Remove the cane from the client to protect their safety.
- C. Teach the client about the proper length of a cane.
- D. Have the client use a wheelchair rather than the cane.
Correct Answer: C
Rationale: Teaching the client about proper cane length (handle at wrist level when arm is relaxed) promotes safe and effective mobility.