Nokea
The nurse is preparing to check a client for Trousseau's sign. Which equipment should the nurse obtain?
- A. Tongue blade
- B. Blood pressure cuff
- C. Reflex hammer
- D. Stethoscope
Correct Answer: B
Rationale: Trousseau’s sign is elicited by inflating a blood pressure cuff on the arm to induce carpopedal spasm indicating hypocalcemia. The other equipment is not used for this assessment.
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A client with a history of colorectal cancer is admitted with complaints of abdominal pain. The nurse should give priority to:
- A. Monitoring for obstruction
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Abdominal pain in colorectal cancer may indicate obstruction, a serious complication requiring immediate monitoring.
A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, 'I just couldn't take it anymore.' The nurse's best response to this disclosure would be:
- A. You shouldn't do things like that, just tell someone you feel bad.
- B. Tell me more about what you couldn't take anymore.
- C. I'm sure you probably didn't mean to kill yourself.
- D. How long have you been in the hospital?
Correct Answer: B
Rationale: Disapproving gives the impression that the nurse has a right to pass judgment on the client's thoughts, actions, or ideas. Giving a broad opening gives the client encouragement to continue with verbalization. Failing to acknowledge the client's feelings conveys a lack of understanding and empathy. Changing the subject takes the conversation away from the client and is indicative of the nurse's anxiety or insensitivity.
A client with a history of heart failure is admitted with complaints of dyspnea. The nurse should give priority to:
- A. Administering diuretics
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring temperature
Correct Answer: A
Rationale: Diuretics reduce fluid overload in heart failure, relieving dyspnea and improving oxygenation.
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
- A. Two finger widths are noted between the axilla and the top of the crutch.
- B. The client bears weight on his hands when ambulating.
- C. The crutches and the client's feet move alternately.
- D. The client bears weight on his axilla when standing.
Correct Answer: D
Rationale: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.
A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?
- A. Astigmatism
- B. Hyperopia
- C. Myopia
- D. Amblyopia
Correct Answer: C
Rationale: Visual images are blurred and distorted. Symptoms are headaches, burning eyes, fatigue, squinting, and difficulty reading. These symptoms are classic for myopia. Amblyopia is not a refractive error. It is a loss of vision in one or both eyes.