Nokea
The nursing assessment of a client with osteomyelitis of the left great toe reveals pain with partial weight-bearing, unsteady gait, and fever. The priority nursing diagnosis for the client is:
- A. Impaired physical mobility.
- B. Impaired skin integrity.
- C. Ineffective coping.
- D. Risk for injury.
Correct Answer: D
Rationale: Risk for injury is the priority due to unsteady gait and pain, which increase the likelihood of falls in a client with osteomyelitis.
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For which of the following should the nurse be especially alert when caring for a term neonate, who weighed 10 lb at birth, 1 hour after a vaginal delivery?
- A. Hypoglycemia.
- B. Hypercalcemia.
- C. Hypermagnesemia.
- D. Hyperbilirubinemia.
Correct Answer: A
Rationale: The neonate would be considered large for gestational age (LGA) because the neonate weighs more than 4,000 g (90th percentile). Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other complications like hyperbilirubinemia may occur, but hypoglycemia is the priority concern within the first hour.
A client with alcohol dependence states, 'I feel so bad because of what I've done to my wife and kids. I'm just no good.' Which of the following responses by the nurse is most appropriate?
- A. You'll need to make up for a lot of things
- B. They will need to forgive your shortcomings
- C. Alcohol dependence is a disease that can be treated
- D. Alcoholism is painful for everyone involved
Correct Answer: C
Rationale: Framing alcohol dependence as a treatable disease offers hope and reduces self-blame, supporting recovery. Other responses may reinforce guilt or are less therapeutic.
The nurse should consider which of the following principles when developing a plan of care to manage a client's pain from cancer?
- A. Individualize the pain medication regimen for the client.
- B. Select medications that are least likely to lead to addiction.
- C. Administer pain medication as soon as the client requests it.
- D. Change pain medications periodically to avoid drug tolerance.
Correct Answer: A
Rationale: Individualizing the regimen ensures effective pain control tailored to the client's needs, considering cancer pain's variable nature.
After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
- A. Evidence of ruptured membranes.
- B. Viability status of the fetus.
- C. Indications that contractions have ceased.
- D. Fetal heart rate variability.
Correct Answer: C
Rationale: A negative contraction stress test indicates no fetal distress, so the nurse should next ensure contractions have ceased to prevent preterm labor. The other assessments are less immediate.
You are the Assistant Director of Nursing in a multi ethnic and culturally diverse inner city acute care facility. You will be chairing a committee to develop a philosophy of nursing that addresses these facility characteristics and the characteristics of the clients. Which theoretical framework would you recommend that this committee should consider when addressing multi ethnicity and the culturally diverse nature of this facility for this philosophy?
- A. Jean Watson's
- B. Martha Rogers'
- C. Nagi's theory
- D. Madeleine Leininger's theory
Correct Answer: D
Rationale: Madeleine Leininger's theory of Transcultural Nursing focuses on providing culturally congruent care, making it the most appropriate framework for addressing the needs of a multi-ethnic and culturally diverse population.