Nokea
The nurse is caring for an adult who is admitted in right heart failure. Which observation is most consistent with this condition?
- A. Distended neck veins
- B. Facial edema
- C. Renal failure
- D. Constipation
Correct Answer: A
Rationale: Right heart failure causes systemic venous congestion, leading to distended neck veins due to increased jugular venous pressure. Facial edema, renal failure, and constipation are less specific to right heart failure.
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A child in Bryant's traction. The nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg during neurovascular assessment.
The nurse should
- A. record the observation.
- B. encourage the child to move the foot.
- C. cover the colder foot with a sock.
- D. notify the physician.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) ignores possibility that Ace bandage is too tight (2) does not relieve the circulation problem (3) does not relieve the circulation problem (4) correct-assessment indicates that Ace bandage is too tight and needs readjusting
A client with a hiatal hernia.
A nursing assessment of a client with a hiatal hernia is MOST likely to reveal
- A. a bulge in the lower right quadrant.
- B. pain at the umbilicus radiating down into the groin.
- C. a burning sensation in the midepigastric area each day before lunch.
- D. complaints of awakening at night with heartburn.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) suggests an inguinal hernia (2) suggests an inguinal hernia (3) pain usually does not develop during the day with an empty stomach (4) correct-classic symptom of hiatal hernia associated with reflux
The client is being admitted for surgery. During the admission assessment, the client states that she usually has 8 to 10 alcoholic drinks a day. How should the nurse reply?
- A. What type of alcohol do you drink?
- B. How long have you been drinking alcohol?
- C. When was your last drink?
- D. Why do you drink so much?
Correct Answer: C
Rationale: Admitting to 8 to 10 alcoholic drinks a day is suggestive of alcoholism. It is important to know when the client last had a drink of alcohol in order to anticipate the onset of withdrawal symptoms. The type of alcohol the client drinks, how long the client has been drinking, and why the client drinks are not the key issues. The key issue is when to anticipate withdrawal symptoms.
An adult man believes that someone is poisoning his food. What is the best nursing action in response to this belief?
- A. Explain to him that no one is poisoning his food
- B. Tell him that the food is prepared in the hospital under secure conditions
- C. Taste his food to assure him that it is not being poisoned
- D. Offer him food that is in individual containers
Correct Answer: D
Rationale: Offering individually packaged food addresses the delusion non-confrontationally, reducing anxiety. Explaining, assuring, or tasting may escalate distrust.
When the nurse walks into a client's room, the client states, 'I just love hot-blooded redheads.' The client pats his bed and says, 'Why don't you sit down here and get off your feet for a while.'
Which of the following responses by the nurse is BEST?
- A. I feel very uncomfortable when you make those suggestive remarks. It makes it difficult for me to do my job.'
- B. I don't think my husband or your wife would like me doing that.'
- C. You must be very lonesome. I'll come back later and spend some time with you.'
- D. I bet you flirt with all the nurses like that.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-nurse should confront client about inappropriate sexual behavior (2) should confront the client (3) reinforces inappropriate behavior (4) confront the client about inappropriate and unwanted behavior