Nokea
The nurse is caring for assigned clients. The nurse should first check the client with
- A. liver cirrhosis who has a decreased RBC count and is reporting pruritis
- B. pneumonia who has an elevated WBC count and coarse crackles bilaterally
- C. atrial fibrillation who has an irregular heart rate of 122/min and is reporting palpitations
- D. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration
Correct Answer: D
Rationale: Pericarditis with paradoxical pulse (D) suggests tamponade, requiring immediate assessment. Atrial fibrillation (C), pneumonia (B), and cirrhosis (A) are less urgent.
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An adult client was admitted for congestive heart failure today. An IV is running. The nurse enters the room and notes that the client is having increased difficulty breathing. Before calling the physician, what action should the nurse take?
- A. Increase the IV drip rate
- B. Place the client in a supine position
- C. Ask the client if this has happened before
- D. Raise the head of the bed
Correct Answer: D
Rationale: Raising the head of the bed improves breathing in congestive heart failure by reducing pulmonary congestion. Increasing IV rate, supine positioning, or questioning delays intervention.
The nurse is reinforcing teaching to the parents of a hospitalized 3-month-old about separation anxiety. The nurse notices that the parents still seem concerned about leaving the infant while they work. Which statement by one of the parents indicates that the teaching has been effective?
- A. At this age, my baby will not cry because we are leaving.
- B. I know my baby will feel abandoned when we leave.
- C. My baby is too young to sense my anxiety about leaving.
- D. My baby understands that we will return later in the day.
Correct Answer: C
Rationale: Infants at 3 months (C) do not yet exhibit separation anxiety and cannot sense parental anxiety. Crying (A), feeling abandoned (B), and understanding return (D) occur later in development.
A nurse is assigned to a client who is newly admitted for treatment of a frontal lobe brain tumor. Which history offered by the family members would be recognized by the nurse as associated with the diagnosis, and communicated to the provider?
- A. My partner's breathing rate is usually below 12.
- B. I find the mood swings and the change from a calm person to being angry all the time hard to deal with.
- C. It seems our sex life is nonexistent over the past 6 months.
- D. In the morning and evening I hear complaints that reading is next to impossible from blurred print.
Correct Answer: B
Rationale: I find the mood swings and the change from a calm person to being angry all the time hard to deal with. Frontal lobe tumors affect emotions and judgment, causing mood swings and personality changes.
The nurse cares for a hospitalized client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate in the care of this client?
- A. Allow the client to continue to exercise per usual routine
- B. Assist the client in reflecting on triggers of disordered eating
- C. Document the client's daily intake of calories and protein
- D. Remain with the client for the duration of each meal
- E. Weigh the client each morning prior to any oral intake
Correct Answer: B,C,D,E
Rationale: Reflecting on triggers (B), documenting intake (C), staying during meals (D), and daily weighing (E) support recovery. Exercise (A) should be limited to prevent calorie expenditure.
The nurse has a client with knee surgery who is receiving patient-controlled analgesia (PCA) of meperidine (Demerol). Which assessment finding would be a priority due to the use of this device and medication?
- A. Pulse rate 108
- B. $100 \mathrm{cc}$ of green emesis
- C. Respiratory rate of 10
- D. Lack of pain relief
Correct Answer: C
Rationale: The patient is in danger of respiratory depression due to narcotic administration; therefore, this would be a priority assessment. Answer A does not relate to the PCA, so it is incorrect. Answer B is not a priority, making it wrong. Pain relief in answer D is important, but not as important as airway, so it is incorrect.