Nokea
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?
- A. I've been having a dull pain at the upper left shoulder.'
- B. My legs have been numb for three months.'
- C. I've only been urinating three times a day lately.'
- D. I don't remember anything in particular, I just haven't felt well.'
Correct Answer: D
Rationale: (A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
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A client with a history of liver failure is admitted with complaints of confusion. The nurse should expect the client to have:
- A. Hyperammonemia
- B. Hypoglycemia
- C. Hypercalcemia
- D. Hypokalemia
Correct Answer: A
Rationale: Liver failure impairs ammonia detoxification, leading to hyperammonemia, which causes hepatic encephalopathy and confusion.
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
- A. November 23rd
- B. December 26th
- C. September 14th
- D. December 9th
Correct Answer: A
Rationale: Naegele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule.
A client with a history of Cushing’s syndrome is admitted with complaints of weight gain. The nurse should expect the client to have:
- A. Moon face
- B. Weight loss
- C. Hypotension
- D. Bradycardia
Correct Answer: A
Rationale: Cushing’s syndrome causes excess cortisol, leading to moon face, central obesity, and weight gain.
The nurse is observing a student gauss administering ear drops to a two-year-old. Which observation by the nurse would indicate correct technique?
- A. Holds the child's head up and extended
- B. Places the head in chin-tuck position
- C. Pulls the pinna down and back
- D. Irrigates the ear before administering medication
Correct Answer: C
Rationale: Pulling the pinna down and back in children straightens the ear canal for proper ear drop administration. Head extension (A), chin-tuck (B), and irrigation (D) are incorrect.
A baby is circumcised. Immediate postoperative care should include:
- A. Applying a loose diaper
- B. Keeping the baby NPO for 4 hours to avoid vomiting
- C. Changing the dressing frequently using dry, sterile gauze
- D. Taking the baby to his mother for cuddling
Correct Answer: D
Rationale: A pressure diaper should be applied to discourage hemorrhage. The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable. Dressing changes should not be dry. Dry dressing will stick. Cuddling after the procedure will hopefully quiet the baby. Feeding is also important if his feeding was withheld prior to the procedure or it is time for a feeding.