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The nurse is measuring the fundal height on a client who is 36 weeks' gestation when the client reports feeling lightheaded. What finding should the nurse expect to note when assessing the client?
- A. Fear
- B. Anemia
- C. A full bladder
- D. Compression of the vena cava
Correct Answer: D
Rationale: Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome (vena cava syndrome) late in pregnancy. Having the client turn onto her left side or elevating the left buttock during fundal height measurement will prevent the problem. Options 1, 2, and 3 are unrelated to this syndrome.
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Which piece of equipment will the nurse routinely use to assess the fetal heart rate of a woman at 16 weeks' gestation?
- A. Fetal heart monitor
- B. An adult stethoscope
- C. Bell of a stethoscope
- D. Ultrasound fetoscope
Correct Answer: D
Rationale: Toward the end of the first trimester, the fetal heart tones can be heard with an ultrasound fetoscope. Options 2 and 3 are not designed to adequately assess the fetal heart rate. A fetal heart monitor is used during labor or in other situations when the fetal heart rate needs continuous monitoring.
The nurse is caring for a client diagnosed with a herniated lumbar intervertebral disk who is experiencing low back pain. Which position should the nurse place the client in to minimize the pain?
- A. Supine with the knees slightly raised
- B. High Fowler's position with the foot of the bed flat
- C. Semi-Fowler's position with the foot of the bed flat
- D. Semi-Fowler's position with the knees slightly raised
Correct Answer: D
Rationale: Clients with low back pain are often more comfortable in the semi-Fowler's position with the knees raised sufficiently to flex the knees (William's position). This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the bed flat or lying in a supine position with the knees raised would excessively stretch the lower back. Keeping the foot of the bed flat will enhance extension of the spine.
The nurse is caring for a child recovering from a tonsillectomy. Which fluid or food item should be offered to the child?
- A. Green Jell-O
- B. Cold soda pop
- C. Butterscotch pudding
- D. Cool cherry-flavored Kool-Aid
Correct Answer: A
Rationale: After tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided because they give the appearance of blood if the child vomits.
A client states, 'I'm sure I have restless leg syndrome.' The nurse determines that the client is in need of further teaching on the condition when the client identifies the presence of which characteristics? Select all that apply.
- A. A heavy feeling in the legs
- B. Burning sensations in the limbs
- C. Symptom relief when lying down
- D. Decreased ability to move the legs
- E. Symptoms that are worse in the morning
- F. Feeling the need to move the limbs repeatedly
Correct Answer: A,C,D,E
Rationale: Restless leg syndrome is characterized by leg paresthesia associated with an irresistible urge to move. The client complains of intense burning or 'crawling-type' sensations in the limbs and subsequently feels the need to move the limbs repeatedly to relieve the symptoms. The symptoms are worse in the evening and night when the client is still.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud's disease. The nurse should assess the trigger of these signs/symptoms by asking which question?
- A. Does being exposed to heat seem to cause the episodes?
- B. Do the signs and symptoms occur while you are asleep?
- C. Does drinking coffee or ingesting chocolate seem related to the episodes?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: C
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity are unrelated to these episodes.