Nokea
The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be:
- A. A false elevation
- B. A false low reading
- C. A blood pressure reading that is correct
- D. A subnormal finding
Correct Answer: A
Rationale: A blood pressure cuff that is too small will result in a false elevation of the blood pressure reading due to increased pressure on the arm.
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A client with metastatic cancer of the lung has just been told the prognosis by the oncologist. The nurse hears the client state, 'I don't believe the doctor; I think he has me confused with another patient.' This is an example of which of Kubler-Ross' stages of dying?
- A. Denial
- B. Anger
- C. Depression
- D. Bargaining
Correct Answer: A
Rationale: The client's statement reflects denial, a stage where patients refuse to accept a terminal diagnosis, per Kubler-Ross' model.
A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV. Which site would be most suitable for this client?
- A. Top of client's right hand
- B. Left antecubital fossa
- C. Top of either foot
- D. Left forearm
Correct Answer: B
Rationale: The left antecubital fossa is suitable as it is away from burned areas (hands, right arm, face, neck) and provides a large vein for IV access.
The nurse is caring for a client receiving pantoprazole. The nurse understands that long-term use of proton pump inhibitors increases the risk of which serious side effects? Select all that apply.
- A. nausea
- B. depression
- C. constipation
- D. rhabdomyolysis
- E. long bone fractures
Correct Answer: D,E
Rationale: Long-term PPI use increases the risk of rhabdomyolysis and long bone fractures due to nutrient malabsorption and muscle damage. Nausea, depression, and constipation are less associated.
The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?
- A. Premature atrial complex
- B. Sinus tachycardia
- C. Atrial flutter
- D. Supraventricular tachycardia
Correct Answer: B
Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.
To minimize confusion in the elderly hospitalized client, the nurse should:
- A. Provide sensory stimulation by varying the daily routine
- B. Keep the room brightly lit and the television on to provide orientation to time
- C. Encourage visitors to limit visitation to phone calls to avoid overstimulation
- D. Provide explanations in a calm, caring manner to minimize anxiety
Correct Answer: D
Rationale: Calm, clear explanations reduce anxiety and confusion in elderly clients, promoting orientation and comfort in the hospital setting.