Nokea
The nurse is reviewing medical-surgical concepts with a group of nursing students. When discussing pain, it is appropriate for the nurse to categorize pain that occurs with short duration as
- A. Chronic pain
- B. Acute pain.
- C. Referred pain.
- D. Neuropathic pain.
Correct Answer: B
Rationale: Acute pain is short-duration, typically linked to injury or surgery. Chronic pain is persistent, referred pain is felt elsewhere, and neuropathic pain involves nerve damage.
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The nurse is planning care for a pediatric client being admitted with pulmonary tuberculosis (TB). Which of the following interventions should the nurse include in the client's plan of care?
- A. consult the infection control nurse
- B. room the client with an uninfected client 6 feet apart
- C. place the client with another client who has varicella in the shared airborne isolation room 6 feet apart
- D. place the client in a private room with monitored positive airflow
Correct Answer: A
Rationale: Consulting the infection control nurse ensures proper airborne precautions for TB. Cohorting or positive airflow is inappropriate.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
The nurse cares for geriatric clients. What would the nurse emphasize as an increased risk for this client population?
- A. Blepharitis and chalazion
- B. Myopia and strabismus
- C. Exophthalmos and presbyopia
- D. Glaucoma and cataracts
Correct Answer: D
Rationale: Glaucoma and cataracts are common age-related eye conditions, increasing vision loss risk. Other conditions are less prevalent or age-specific.
The nurse is working with a group of students and a student asks what cyanosis means. What is the nurse's best response?
- A. Cyanosis is a condition characterized by a yellowish discoloration of the skin and mucous membranes due to excessive oxygenation.
- B. Cyanosis is the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood.
- C. Cyanosis is the primary indication that the client has pneumonia.
- D. Cyanosis is the bluish discoloration of the skin and mucous membranes due to poor peripheral circulation, even in the presence of normal oxygen levels.
Correct Answer: B
Rationale: Cyanosis is blue discoloration due to poorly oxygenated blood. Yellowish discoloration is jaundice, it’s not specific to pneumonia, and circulation issues alone don’t cause it if oxygen is normal.
The nurse is caring for a client who has a prescribed regular insulin sliding scale. At 0800, the client's capillary blood glucose (CBG) was 258 mg/dl (14.29 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. At 1215 the CBG was 288 mg/dl (15.984 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. At 1730 the CBG was 254 mg/dI (14.097 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The nurse should do which of the following at 1730?
- A. Administer 8 units of regular insulin
- B. Administer 6 units of regular insulin
- C. Notify the primary health care provider (PHCP)
- D. Withhold the prescribed insulin
- E. Modify the client's prescribed diet to low sodium
Correct Answer: B,C
Rationale: Per the sliding scale, 254 mg/dL requires 6 units of insulin, and three consecutive CBGs >250 mg/dL require notifying the PHCP.