Nokea
The nurse would identify which of the following clients as being at the highest risk for developing a pulmonary embolus?
- A. A 19-year-old four days postpartum with an obstetrical history of placenta previa.
- B. An obese 40-year-old man with multiple pelvic fractures from an auto accident two days ago.
- C. A 65-year-old woman who had a fractured hip repaired 10 days ago and who is in physical therapy daily.
- D. A 22-year-old leukemic client with a platelet count of 120,000/mm³ and a hemoglobin level of 9.0 g.
Correct Answer: B
Rationale: obesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli
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A five-year-old is scheduled for a lumbar puncture (LP). Which of the following nursing actions would BEST prepare the child for the procedure?
- A. Explain the procedure in detail.
- B. Show a video of the procedure.
- C. Do a mock run-through of the procedure.
- D. Answer all questions simply and honestly.
Correct Answer: C
Rationale: excellent method to use with a child because it incorporates actually 'feeling' many aspects of the procedure as they are explained
The nurse is assessing a client with a diagnosis of detached retina. Which of the following observations would support this diagnosis?
- A. Loss of acuity in the peripheral visual field.
- B. Increased lacrimation, blurred vision.
- C. Conjunctivitis, dilated pupils bilaterally.
- D. Photophobia, loss of a portion of the visual field.
Correct Answer: D
Rationale: bright flashes of light and client stating that portion of visual field is dark are classic symptoms
A client is scheduled for a cardiac catheterization, and the nurse teaches him about the procedure. What statements, if made by the client, would indicate to the nurse that he understands the teaching?
- A. I'm going to feel cold during the procedure.
- B. I can get up and walk to the bathroom immediately after the procedure.
- C. The nurse will be checking my foot pulses after the procedure.
- D. I won't be able to eat for 24 hours before the procedure.
Correct Answer: C
Rationale: peripheral pulses checked every 15 min for 1 h, then every 30 min for 2 h, then every 4 h
A middle-aged female client begins outpatient therapy sessions with a psychiatric clinical nurse specialist for management of a phobic disorder. Which of the following nursing interventions should be an initial approach in symptom reduction?
- A. Referral for psychopharmacologic intervention.
- B. Group psychotherapy.
- C. Systematic desensitization.
- D. Biofeedback.
Correct Answer: C
Rationale: phobic disorders are learned responses; learned responses can be unlearned through certain techniques, such as behavioral modification; systematic desensitization is a form of behavior modification; is a strategy used in conjunction with deep muscle relaxation to decrease the extreme response to anxiety-producing situations as they are gradually exposed; then exposure is increased; goal is to eradicate the phobic response by replacing it with the relaxation response
A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to
- A. avoid intercourse for 48 hours before the examination.
- B. avoid douching for 24 hours prior to her appointment.
- C. withhold all foods and fluids 12 hours before the appointment.
- D. save her first voided urine specimen the morning of her appointment.
Correct Answer: B
Rationale: douching would affect appearance of cells in vaginal smear, would make test inaccurate