Nokea
The nurse is teaching a client how to manage a nosebleed. Which of the following instructions would be appropriate to give the client?
- A. Tilt your head backward and pinch your nose.
- B. Lie down flat and place an ice compress over the bridge of the nose.
- C. Blow your nose gently with your neck
- D. Sit down, lean forward, and pinch the soft portion of your nose.
Correct Answer: D
Rationale: Sitting and leaning forward while pinching the soft portion of the nose compresses the bleeding site and prevents blood from flowing down the throat. Tilting backward can cause swallowing of blood. Lying flat is not recommended. Blowing the nose can worsen bleeding.
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A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Which of the following interventions is most important for the nurse to implement in the preoperative period?
- A. Assess the temperature in the affected area
- B. Monitor the radial pulse in the affected arm
- C. Protect the extremity from cold
- D. Avoid using the arm for a venipuncture
Correct Answer: D
Rationale: Avoiding venipuncture in the affected arm is critical preoperatively to preserve vascular integrity and prevent complications (e.g., hematoma) that could affect the axillary-to-axillary bypass surgery. Monitoring pulses, assessing temperature, and protecting from cold are important but less urgent than preventing vascular trauma.
A 57-year-old client has difficulty with mobility after cancer treatment therapies and states, 'Why should I bother stretching my muscles? It doesn't seem to make any difference what I do.' The nurse responds by helping the client establish reasonable activity goals, choose their own health care from the menu, and make choices about her daily activities. These interventions represent the nurse's attempt to address which of the following nursing diagnoses?
- A. Ineffective coping.
- B. Powerlessness.
- C. Risk prone health behavior.
- D. Complicated grieving.
Correct Answer: B
Rationale: The client's statement reflects powerlessness, and the nurse's interventions aim to restore a sense of control through goal-setting and decision-making.
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) best reflects the client's symptoms of tiring rapidly due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported.
Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will:
- A. Maintain a fluid intake of 800 mL every 24 hours.
- B. Experience chills only once a day.
- C. Cough productively without chest discomfort.
- D. Experience less nasal obstruction and discharge.
Correct Answer: D
Rationale: An expected outcome for recovery from an upper respiratory tract infection is reduced nasal obstruction and discharge, indicating resolution of inflammation and infection. A fluid intake of 800 mL is too low; 1,500–2,000 mL is more appropriate. Chills are not a typical measure of recovery. Productive coughing without discomfort may occur but is less specific than reduced nasal symptoms.
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client:
- A. "You will need to accept the necessity for a quiet and inactive lifestyle."
- B. "Keep active, use stress reduction strategies, and avoid fatigue."
- C. "Follow good health habits to change the course of the disease."
- D. "Practice using the mechanical aids that you will need when future disabilities arise."
Correct Answer: B
Rationale: Encouraging activity, stress reduction, and fatigue management supports the client's quality of life and symptom control. Inactivity, changing disease course, or premature focus on aids are less appropriate.