Nokea
A child in Bryant's traction. The nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg during neurovascular assessment.
The nurse should
- A. record the observation.
- B. encourage the child to move the foot.
- C. cover the colder foot with a sock.
- D. notify the physician.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) ignores possibility that Ace bandage is too tight (2) does not relieve the circulation problem (3) does not relieve the circulation problem (4) correct-assessment indicates that Ace bandage is too tight and needs readjusting
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A client with schizophrenia is receiving haloperidol (Haldol) 5 mg T.I.D. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?
- A. Oculogyric crisis
- B. Tardive dyskinesia
- C. Nystagmus
- D. Dysphagia
Correct Answer: A
Rationale: Oculogyric crisis. This refers to involuntary muscle spasm of the eye, a known side effect of haloperidol.
Which individual is at greatest risk for developing hypertension?
- A. 45 year-old African American attorney
- B. 60 year-old Asian American shop owner
- C. 40 year-old Caucasian nurse
- D. 55 year-old Hispanic teacher
Correct Answer: A
Rationale: 45 year-old African American attorney. The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.
The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of inTest inal obstruction?
- A. Protruding soft abdomen with frequent diarrhea.
- B. Distended abdomen with ascites.
- C. Minimal bowel sounds in all four quadrants.
- D. Distended abdomen with complaints of pain.
Correct Answer: D
Rationale: if an obstruction is present, the abdomen will become distended and painful
The nurse is planning care for a client with a long history of smoking and newly diagnosed chronic obstructive pulmonary disease (COPD). Which of the following should the nurse include in the client's teaching plan?
- A. Explain the need to avoid large crowds during the winter months.
- B. Instruct the client to install air conditioning in the home.
- C. Teach the client to breathe in through the nose and out through the mouth.
- D. Encourage the client to consume three large meals daily.
Correct Answer: A
Rationale: Clients with COPD are at high risk for respiratory infections, which can exacerbate symptoms. Avoiding large crowds during winter reduces exposure to viruses. Options B, C, and D are less relevant: air conditioning is not essential, nasal breathing is not specific, and large meals can cause dyspnea due to gastric pressure.
A child with epiglottitis.
Which of the following nursing observations would indicate to the nurse that a child with epiglottitis is having an early complication of hypoxemia?
- A. Heart rate of 148 beats per minute.
- B. Bluish discoloration of the skin.
- C. Bluish discoloration around the mouth.
- D. Difficulty swallowing.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to epiglottitis. (1) correct-heart rate correlates with hypoxemia and is an early finding, along with restlessness (2) cyanosis, late sign (3) circumoral cyanosis, late sign (4) sign of epiglottitis