Nokea
The sense of hearing is assessed using which standardized test?
- A. The Taylor test
- B. The Rinne test
- C. The Babinski test
- D. The APGAR test
Correct Answer: B
Rationale: The Rinne test is a standardized test used to assess hearing by comparing air and bone conduction using a tuning fork.
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While assessing the psychosocial aspects of a primigravid client at 30 weeks' gestation, which of the following feelings are expected?
- A. Vulnerability.
- B. Confirmation.
- C. Ambivalence.
- D. Body image disturbance.
Correct Answer: C
Rationale: Ambivalence is common in pregnancy, reflecting mixed emotions about impending motherhood and life changes.
A client has cystitis. The nurse should further assess the client for:
- A. Flank pain.
- B. Oliguria.
- C. Nausea and vomiting.
- D. Foul-smelling urine.
Correct Answer: D
Rationale: Foul-smelling urine is a common symptom of cystitis due to bacterial infection. Flank pain and oliguria are more indicative of pyelonephritis.
The nurse is caring for a client with a history of venous thromboembolism who is prescribed rivaroxaban (Xarelto). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild bruising.
- B. Bleeding gums.
- C. Headache.
- D. Nausea.
Correct Answer: B
Rationale: Bleeding gums indicate a potential bleeding complication with rivaroxaban, requiring immediate reporting.
The nurse should instruct a client who is taking dexamethasone (Decadron) and furosemide (Lasix) to report:
- A. Excitability.
- B. Muscle weakness.
- C. Diarrhea.
- D. Increased thirst.
Correct Answer: B
Rationale: Muscle weakness is a serious side effect of dexamethasone (steroid-induced myopathy) and furosemide (potassium loss), requiring prompt reporting.
The nurse is monitoring a client who has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). Which observation in the PVCs would indicate to the nurse that this therapy is ineffective?
- A. Occur in pairs
- B. Be unifocal in appearance
- C. Be fewer than 6 per minute
- D. Fall after the end of the T wave
Correct Answer: A
Rationale: PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave.