Nokea
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
- A. The presence of scant bloody discharge
- B. Frequent urination
- C. The presence of green-tinged amniotic fluid
- D. Moderate uterine contractions
Correct Answer: C
Rationale: Green-tinged amniotic fluid indicates meconium, a sign of fetal distress requiring immediate reporting.
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The first exercise that should be performed by the client who had a mastectomy 1 day earlier is:
- A. Walking the hand up the wall
- B. Sweeping the floor
- C. Combing her hair
- D. Squeezing a ball
Correct Answer: D
Rationale: Squeezing a ball is a gentle initial exercise to restore arm mobility.
The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80,000. It will be most important to teach the client and family about:
- A. Bleeding precautions
- B. Prevention of falls
- C. Oxygen therapy
- D. Conservation of energy
Correct Answer: A
Rationale: With a platelet count of 80,000, the client is at risk for bleeding, so teaching bleeding precautions is critical to prevent complications.
A client with schizophrenia spends much of his time pacing the floor, rocking back and forth, and moving from one foot to another. The client's behaviors are an example of:
- A. Dystonia
- B. Tardive dyskinesia
- C. Akathisia
- D. Oculogyric crisis
Correct Answer: C
Rationale: Akathisia is characterized by restlessness and constant movement, often a side effect of antipsychotic medications, as described.
A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can use use artificial sweeteners to keep me from gaining too much weight when I get pregnant.
- B. I need to go back on a low-phenylalanine diet before I get pregnant.
- C. Fresh fruits and raw vegetables will make good between-meal snacks for me.
- D. My baby could be mentally retarded if I don't stick to a diet eliminating phenylalanine.
Correct Answer: A
Rationale: Artificial sweeteners like aspartame contain phenylalanine, which is harmful in PKU, so the client's statement indicates a need for further teaching.
A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:
- A. Slow pulse rate, weight loss, diarrhea, and cardiac failure
- B. Weight gain, lethargy, slowed speech, and decreased respiratory rate
- C. Rapid pulse, constipation, and bulging eyes
- D. Decreased body temperature, weight loss, and increased respirations
Correct Answer: B
Rationale: Myxedema (severe hypothyroidism) presents with weight gain, lethargy, slowed speech, and decreased respiratory rate due to metabolic slowing.