Nokea
The nurse is contributing to a staff education program about assessing the urinary system. Which statement by a nurse would indicate a correct understanding of the program?
- A. The bladder should be nontender and nonpalpable when it is empty
- B. Dark brown urine may indicate that the client has a urinary tract infection
- C. I should be able to palpate both kidneys regardless of the client’s abdominal girth
- D. I will assess for tenderness of the kidneys by performing blunt percussion over the client’s lower abdomen
Correct Answer: A
Rationale: An empty bladder is nontender and nonpalpable, indicating correct understanding. Dark brown urine suggests dehydration or other issues, not UTI; kidneys are not always palpable; and percussion is over the costovertebral angle, not lower abdomen.
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An adult client who had a cervical laminectomy is returned to her room on the nursing care unit. The postanesthesia nurse reports that the client is awake and has stable vital signs. The nurse should position the client in which of the following positions?
- A. Supine
- B. Semi-reclining
- C. Side-lying
- D. Prone
Correct Answer: C
Rationale: Side-lying position promotes comfort and maintains spinal alignment post-cervical laminectomy, reducing strain on the surgical site. Supine or prone positions may increase pressure on the neck, and semi-reclining is less optimal for spinal stability.
The nurse is collecting data from a client with Bell’s palsy. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. Inability to smile symmetrically
- B. Frequent blinking of the affected eye
- C. Shock-like pain in the lips and gums
- D. Loss of forehead and brow movements
- E. Decreased lacrimation on the affected side
Correct Answer: A,D,E
Rationale: Bell’s palsy causes unilateral facial weakness, leading to asymmetrical smiling, loss of forehead/brow movement, and reduced lacrimation. Frequent blinking is unlikely due to impaired muscle control, and shock-like pain is typical of trigeminal neuralgia.
The nurse is reinforcing teaching to a client who is newly diagnosed with conversion disorder. The client begins crying and states, 'The health care provider must think I’m crazy because of my diagnosis.' What is the best response to the client?
- A. Conversion disorder is a diagnosis that acknowledges your symptoms are real, even if there isn’t a physical cause
- B. I am very sorry to hear this, but are you sure that’s what the provider meant? Maybe you misunderstood
- C. The health care provider is probably wrong. I’ll give you the information to contact my health care provider
- D. Why do you think you were diagnosed with conversion disorder?
Correct Answer: A
Rationale: Reassuring the client that conversion disorder validates real symptoms without a physical cause reduces stigma and clarifies the diagnosis. Other responses dismiss, question, or deflect the client’s concerns.
A laboring woman prefers to lie in the supine position during labor. The nurse teaches her that this is not a good position for which reason?
- A. It will cause more back pressure.
- B. Her baby will not come down well into the pelvis.
- C. Her blood pressure may drop and cause the baby's heart rate to drop.
- D. Contractions will be too close together, not giving her a rest.
Correct Answer: C
Rationale: Supine position can compress the vena cava, causing maternal hypotension and reduced fetal perfusion, leading to fetal heart rate drops.
The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?
- A. Ask family members to dress the client
- B. Encourage the client to dress more quickly
- C. Allow the client the time needed to dress
- D. Demonstrate methods on how to dress more quickly
Correct Answer: C
Rationale: Allow the client the time needed to dress. Clients with Parkinson's disease often wish to take care of themselves but become very upset when hurried and then are unable to manage at all.