Nokea
The nurse is teaching a client about managing osteoarthritis pain. Which non-pharmacologic intervention should be included?
- A. Apply ice packs for 30 minutes at a time.
- B. Maintain a high-protein diet.
- C. Use a heating pad on high setting.
- D. Perform gentle range-of-motion exercises.
Correct Answer: D
Rationale: Gentle range-of-motion exercises maintain joint mobility and reduce stiffness in osteoarthritis.
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Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will:
- A. Demonstrate appropriate use of analgesics to control pain.
- B. Explain the rationale for eliminating alcohol from the diet.
- C. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months.
- D. Eliminate contact sports from his or her lifestyle.
Correct Answer: B
Rationale: Eliminating alcohol is critical for clients with peptic ulcer disease, as it irritates the gastric mucosa and can exacerbate symptoms. The other options are less directly related to the management of peptic ulcer disease.
A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine via PCA 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should:
- A. Discontinue the PCA pump.
- B. Administer oxygen.
- C. Take the client's blood pressure.
- D. Assist the client back to bed.
Correct Answer: C
Rationale: Dizziness after morphine suggests possible hypotension. Taking the blood pressure identifies the cause and guides further action, such as fluid administration or repositioning.
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
- A. Head trauma.
- B. Electrolyte imbalance.
- C. Congenital defect.
- D. Epilepsy.
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
A client receiving TPN reports sudden chest pain and dyspnea. Which action should the nurse take first?
- A. Stop the TPN infusion.
- B. Administer oxygen as ordered.
- C. Notify the physician.
- D. Check the client's blood glucose.
Correct Answer: C
Rationale: Sudden chest pain and dyspnea in a client receiving TPN may indicate a serious complication like an air embolism or infection, requiring immediate physician notification. Stopping the infusion or checking glucose is premature, and oxygen requires an order. CN: Physiological adaptation; CL: Synthesize
What is the nurse's priority when a client experiences a seizure?
- A. Restrain the client.
- B. Protect the airway.
- C. Administer oxygen.
- D. Record the duration.
Correct Answer: B
Rationale: Protecting the airway is the priority to ensure oxygenation during a seizure.