Nokea
The nurse using healing touch affects a client's pain primarily through:
- A. Energy fields.
- B. Touch therapy.
- C. Massage.
- D. Hypnosis.
Correct Answer: A
Rationale: Healing touch primarily uses energy fields to promote relaxation and pain relief, distinct from massage, physical touch therapy, or hypnosis.
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A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Encourage the client to cough and deep breathe.
- C. Auscultate the lungs to detect abnormal breath sounds.
- D. Contact the physician.
Correct Answer: D
Rationale: Sudden dyspnea, tachypnea, and chest discomfort suggest a pulmonary embolism, a medical emergency. Contacting the physician first ensures rapid intervention. Elevating the bed, encouraging coughing, or auscultating lungs delays critical treatment.
The nurse is teaching a caregiver how to administer an injection of enoxaparin. Which statement, if made by the caregiver, would require further teaching?
- A. "I will give this injection in the abdomen."
- B. "I should give this injection at a 30 degree angle."
- C. "Acetaminophen is safe while taking this medication for any aches or pains."
- D. "A soft toothbrush should be used while taking this medicine."
Correct Answer: B
Rationale: Enoxaparin is administered subcutaneously at a 90-degree angle, not 30 degrees, to ensure proper absorption.
An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program?
- A. Giving the client a written exercise program.
- B. Explaining the exercise program to the client's spouse.
- C. Reassuring the client that he or she can do the exercise program.
- D. Tailoring a program to the client's needs and abilities.
Correct Answer: D
Rationale: Tailoring the exercise program to the client's needs and abilities ensures it is feasible and sustainable, promoting adherence.
On the evening of surgery for total knee replacement, a client wants to get out of bed. To safely assist the client the nurse should do which of the following?
- A. Encourage the client to apply full weightbearing.
- B. Order a walker for the client.
- C. Place a straight-backed chair at the foot of the bed.
- D. Apply a knee immobilizer.
Correct Answer: D
Rationale: A knee immobilizer ensures stability and safety during initial transfers post-surgery.
A client at risk for lung cancer asks why he is scheduled for a computed tomography (CT) scan as part of his initial workup. The nurse's best response is which of the following?
- A. CT is far superior to magnetic resonance imaging for evaluating lymph node metastasis.
- B. CT is noninvasive and readily available.
- C. CT is useful for distinguishing small differences in tissue density and detecting nodal involvement.
- D. CT can distinguish a malignant from a nonmalignant adenopathy.
Correct Answer: C
Rationale: CT scans are valuable in lung cancer workups because they can detect small differences in tissue density and identify nodal involvement, aiding in staging and diagnosis.