Nokea
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.
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A client is admitted for treatment of hypoparathyroidism. Based on the client's diagnosis, the nurse would anticipate an order for:
- A. Potassium
- B. Magnesium
- C. Calcium
- D. Iron
Correct Answer: C
Rationale: The parathyroid is responsible for calcium and phosphorus absorption. Clients with hypoparathyroidism have hypocalcemia. Answers A, B, and D are not associated with hypoparathyroidism; therefore, they are incorrect.
The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as the cause of the findings?
- A. Decreased cardiac output
- B. Tissue hypoxia
- C. Cerebral edema
- D. Reduced oxygen saturation
Correct Answer: B
Rationale: Tissue hypoxia. Iron deficiency anemia reduces oxygen-carrying capacity, causing tissue hypoxia.
The nurse is talking with the parent of a 1-day-old newborn who had a circumcision using the plastic ring method. Which of the following statements by the parent would require follow-up?
- A. I will contact the health care provider if bleeding does not stop with gentle pressure
- B. I should avoid using alcohol-based cleansing wipes during diaper changes
- C. I need to leave the device in place and allow it to fall off on its own
- D. I understand that yellow exudate on the area is a sign of infection
Correct Answer: D
Rationale: Yellow exudate is normal during circumcision healing, not a sign of infection, requiring further teaching. Contacting the provider for persistent bleeding, avoiding alcohol wipes, and leaving the device are correct.
The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, 'I have decided that I do not want to continue treatment.' Which of the following responses would be appropriate for the nurse to make?
- A. That is not an easy choice to make. I will notify your health care provider of your decision
- B. Have you considered how this decision might affect your spouse and children?
- C. I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life
- D. Have you discussed this decision with someone else that you trust?
Correct Answer: A
Rationale: Acknowledging the decision’s difficulty and notifying the provider respects autonomy and ensures follow-up. Other responses judge, guilt, or deflect the client’s choice.
The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience
- A. high fever
- B. nausea
- C. face and neck edema
- D. night sweats
Correct Answer: B
Rationale: nausea. Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling.