Nokea
The wife of a terminally ill client asks the nurse, 'Why is my husband having frequent bowel movements if he is not eating?' Which of the following responses by the nurse informs the wife about the client's condition?
- A. I know he is having frequent loose stools and it is distressing for you, but that's just the way it is.
- B. I don't know when the bowels will shut down, but they will eventually.
- C. The pain medication will eventually help to slow the process of bowel function.
- D. The intestines still produce some waste products even when a person is not eating.
Correct Answer: D
Rationale: The intestines continue to produce waste from residual secretions and cellular turnover, even with minimal intake, explaining the frequent bowel movements.
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A client with renal calculi reports sudden cessation of pain. The nurse should:
- A. Strain all urine.
- B. Administer analgesics.
- C. Check vital signs.
- D. Encourage bed rest.
Correct Answer: A
Rationale: Sudden pain cessation may indicate stone passage; straining urine confirms this.
The nurse caring for a client who is receiving radiation therapy for laryngeal cancer should assess the client for which of the following?
- A. Diarrhea.
- B. Improved energy level.
- C. Dysphagia.
- D. Normal white blood cell count.
Correct Answer: C
Rationale: Dysphagia (difficulty swallowing) is a common side effect of laryngeal radiation due to inflammation and irritation of the throat and esophagus.
The client with a laryngectomy is being discharged. The nurse should determine that the client understands to do which of the following self-care measures? Select all that apply.
- A. Provide humidification in the home.
- B. Use a protective shield over the stoma for bathing.
- C. Consume a liberal intake of fluids (2 to 3 L/day).
- D. Limit spicy seasonings on food.
- E. Follow a low-fiber diet.
Correct Answer: A,B,C
Rationale: Self-care measures include home humidification to keep the airway moist, using a stoma shield during bathing to prevent water entry, and consuming 2-3 L/day of fluids to maintain hydration. Spicy foods and low-fiber diets are not typically restricted.
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first:
- A. Ask what medications the client is taking.
- B. Complete a history and health assessment.
- C. Identify the time of onset of the stroke.
- D. Determine if the client is scheduled for any surgical procedures.
Correct Answer: C
Rationale: The time of stroke onset is critical for t-PA administration, as it must be given within a specific window (typically 3-4.5 hours) to be effective and safe. Other assessments follow this priority.
The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following should the nurse assess next?
- A. Bladder distention.
- B. Headache.
- C. Postoperative pain.
- D. Ability to move the legs.
Correct Answer: A
Rationale: Epidural anesthesia can cause urinary retention due to sensory and motor nerve blockade. Assessing for bladder distention is critical to prevent complications like bladder overdistension.