Nokea
The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
- A. Massage legs frequently
- B. Frequent turning
- C. Moisten skin with lotions
- D. Apply moist heat to reddened areas
Correct Answer: B
Rationale: Frequent turning. Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one area.
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The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, 'I will receive tissue from
- A. a tissue bank.
- B. a pig.
- C. my thigh.
- D. synthetic skin.
Correct Answer: C
Rationale: Autografts are done with tissue transplanted from the client's own skin.
The nurse is performing a neurological assessment on a client post right cerebral vascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention?
- A. Decrease in level of consciousness
- B. Loss of bladder control
- C. Altered sensation of stimuli
- D. Emotional lability
Correct Answer: A
Rationale: Decrease in level of consciousness. A further decrease in the level of consciousness would be indicative of a further progression of the CVA.
The nurse is screening clients for those at risk for developing endometrial cancer. Which of the following clients is at highest risk for developing endometrial cancer?
- A. 42-year-old client who has been taking a progestin-containing oral contraceptive for 10 years
- B. 45-year-old client who has a history of one ectopic pregnancy and two births
- C. 51-year-old client who has polycystic ovary syndrome and is obese
- D. 54-year-old client who has a history of hysterectomy for uterine fibroids
Correct Answer: C
Rationale: Obesity and polycystic ovary syndrome (PCOS) increase endometrial cancer risk due to excess estrogen from adipose tissue and anovulation. Ectopic pregnancy and births are not significant risk factors.
Following a motor vehicle accident, the client does not know where he is or what year it is and has short-term memory impairment. Which nursing action is most appropriate?
- A. Offer several choices to the client.
- B. Give simple directions to the client.
- C. Give the client the details of the care.
- D. Offer written instructions to the client.
Correct Answer: B
Rationale: Simple directions accommodate memory impairment and disorientation, enhancing comprehension and safety post-accident.
While reviewing the chart of an elderly client, the nurse notes that the last recorded temperature for the preceding shift was 104°. There is no documented intervention. The nurse should:
- A. Check the doctor's orders for an antipyretic.
- B. Ask the client whether he has received any medication for his fever.
- C. Call the nurse at home to validate whether the medication was given.
- D. Retake the client's temperature.
Correct Answer: D
Rationale: Retaking the temperature verifies the current status, as the fever may have resolved. Checking orders or asking the client assumes the fever persists, and calling the nurse is impractical.