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The risk for injury during an attack of Ménière'sdisease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?
- A. Place your head between your knees.
- B. Concentrate on rhythmic deep breathing.
- C. Close your eyes tightly.
- D. Assume a reclining or flat position.
Correct Answer: D
Rationale: Assuming a reclining or flat position during a vertigo attack minimizes the risk of falling and injury by stabilizing the client's position.
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Which of the following interventions would be least appropriate for a client who is in a double hip spica cast?
- A. Encouraging the intake of cranberry juice.
- B. Advising the client to eat large amounts of cheese.
- C. Establishing regular times for elimination.
- D. Having the client dangle at the bedside.
Correct Answer: D
Rationale: Dangling at the bedside is inappropriate, as it risks cast damage and improper positioning.
The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective?
- A. 90 percent of clients have not gained weight.
- B. 75 percent of the clients viewed the educational video.
- C. 80 percent of the clients reported that they are taking their medications.
- D. 5 percent of the clients required hospitalization in the last 90 days.
Correct Answer: A,C,D
Rationale: No weight gain (A), medication adherence (C), and low hospitalization rates (D) indicate effective management of heart failure through monitoring and teaching.
Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had a 15% blood loss?
- A. Pulse rate less than 60 bpm.
- B. Respiratory rate of 4 breaths/minute.
- C. Pupils unequally dilated.
- D. Systolic blood pressure less than 90 mm Hg.
Correct Answer: D
Rationale: A 15% blood loss can cause hypovolemic shock, with early signs including hypotension (systolic BP <90 mm Hg) due to reduced circulating volume. Bradycardia, low respiratory rate, and unequal pupils are not typical findings.
The nurse should assess the client with bladder cancer for which of the following?
- A. Suprapubic pain.
- B. Dysuria.
- C. Painless hematuria.
- D. Urine retention.
Correct Answer: C
Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often presenting as the initial sign due to tumor growth causing bleeding without associated pain.
The nurse is preparing to administer ear drops to a client who is six years old. The nurse should perform which action?
- A. Pull the ear pinna down and back
- B. Position the client on their side with the ear to be treated against a pillow
- C. Pull the ear pinna up and back
- D. Place cotton directly into the ear canal after ear drop administration
Correct Answer: C
Rationale: For children over 3 years, pulling the ear pinna up and back straightens the ear canal for proper administration.