Nokea
The patient experiences sudden pain in his right calf while sitting at home. He is diagnosed with deep vein thrombosis (DVT). The first intervention is to
- A. Apply ice packs to the affected area every 4 to 6 hours.
- B. Increase dietary intake of foods rich in vitamin K.
- C. Monitor platelet counts daily.
- D. Use intermittent warm soaks of the affected area.
Correct Answer: C
Rationale: Monitoring platelets is crucial when anticoagulants are administered.
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While recovering from the anesthetic, what is the best position for Mrs. West?
- A. Supine with legs fully extended
- B. Prone with head turned to the side
- C. Lateral Sims with legs flexed
- D. Trendelenburg with head to the side
Correct Answer: D
Rationale: The correct answer is D: Trendelenburg with head to the side. This position helps prevent aspiration by promoting drainage of secretions from the mouth and reducing the risk of airway obstruction. Placing the patient in Trendelenburg position with the head to the side also helps facilitate proper blood flow and ventilation. Supine with legs fully extended (A) may increase the risk of airway obstruction and aspiration. Prone with head turned to the side (B) may obstruct the airway and hinder breathing. Lateral Sims with legs flexed (C) is not suitable for a patient recovering from anesthesia as it may not provide optimal airway clearance and respiratory support.
A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?
- A. Poor impulse control
- B. Inability to discriminate words and letters
- C. Deficits in the right visual field
- D. Motor retardation
Correct Answer: A
Rationale: The correct answer is A: Poor impulse control. When a client has a stroke involving the right cerebral hemisphere, it can affect their ability to regulate emotions and impulses. The right hemisphere is responsible for inhibiting impulsive behavior, so damage to this area can lead to poor impulse control. This can manifest as impulsivity, lack of judgement, and difficulty controlling emotions.
Summary of Incorrect Choices:
B: Inability to discriminate words and letters - This is typically associated with left cerebral hemisphere damage, not right hemisphere.
C: Deficits in the right visual field - This is associated with damage to the left occipital lobe, not the right hemisphere.
D: Motor retardation - Motor functions are controlled by the opposite side of the brain, so right hemisphere damage would typically affect the left side of the body, not motor function in general.
What is the term that describes a type of therapy or medicine used in conjunction with conventional medicine?
- A. Integrative medicine
- B. Alternative therapy
- C. Allopathic medicine
- D. Complementary therapy
Correct Answer: D
Rationale: Complementary therapy works alongside conventional medicine to enhance overall care.
Which technique facilitates interactions between the nurse and client?
- A. Ask questions that can be answered with yes or no.
- B. Sit within the client’s comfort zone.
- C. Avoid making eye contact.
- D. Address clients by their first names.
Correct Answer: B
Rationale: Respecting personal space enhances trust and comfort during interactions.
Which of the following helps the nurse to identify goals, tailor the teaching plan, and evaluate outcomes?
- A. Desire to acquire new information.
- B. Assessment of what the client knows.
- C. Purpose or reason for mastering skills.
- D. Restored independence.
Correct Answer: B
Rationale: Assessing the client's existing knowledge provides a foundation for setting realistic goals and tailoring the teaching plan.