Nokea
The nurse teaches a client about using the crutches, instructing the client to support her weight primarily on which of the following body areas?
- A. Axillae.
- B. Elbows.
- C. Upper arms.
- D. Hands.
Correct Answer: D
Rationale: Weight should be supported on the hands to prevent nerve damage in the axillae.
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A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation?
- A. Tell the client firmly that she needs assistance and help her with her care.
- B. Praise the client for her desire to be independent and give her extra time and encouragement.
- C. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help.
- D. Suggest to the client that if she insists on self-care, she should at least modify her routine.
Correct Answer: B
Rationale: Praising independence and providing extra time respects the client's autonomy while supporting her efforts. Forcing help, labeling her unrealistic, or suggesting modifications may undermine her dignity.
Assessment of the diabetic client for common complications should include examination of the:
- A. Abdomen.
- B. Lymph glands.
- C. Pharynx.
- D. Eyes.
Correct Answer: D
Rationale: Diabetic retinopathy, a common complication, requires regular eye examinations to detect and prevent vision loss.
A client has undergone an amputation of several toes and a femoral-popliteal bypass. The nurse should teach the client that after surgery which of the following leg positions is contraindicated for her while sitting in a chair?
- A. Crossing the legs
- B. Elevating the legs
- C. Flexing the ankles
- D. Extending the knees
Correct Answer: A
Rationale: Crossing the legs is contraindicated post-femoral-popliteal bypass and toe amputation, as it compresses blood vessels, impairing circulation and increasing the risk of graft occlusion or ischemia. Elevating legs, flexing ankles, and extending knees are generally acceptable unless otherwise specified.
The rate at which I.V. fluids are infused is based on the burn client's:
- A. I.V. and body surface area (BSA) burned.
- B. Total body weight and BSA burned.
- C. Total BSA and BSA burned.
- D. Height and weight and BSA burned.
Correct Answer: B
Rationale: The Parkland Formula uses total body weight and percentage of BSA burned to calculate fluid requirements, ensuring adequate resuscitation based on burn severity.
A client receives a thrombolytic agent. The expected outcome of this drug therapy includes:
- A. Improved cerebral perfusion
- B. Decreased vascular permeability
- C. Dissolved emboli
- D. Prevention of further cerebral hemorrhage
Correct Answer: C
Rationale: Thrombolytic agents (e.g., alteplase) dissolve existing clots, such as emboli in pulmonary embolism or arterial occlusion, restoring blood flow. They do not improve cerebral perfusion, decrease vascular permeability, or prevent cerebral hemorrhage (they increase bleeding risk).