Nokea
What should be the nurse's first action for a client with a suspected myocardial infarction (MI)?
- A. Administer nitroglycerin
- B. Monitor cardiac rhythm
- C. Assess the ECG
- D. Assist with positioning
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. This is the nurse's first action for a client with a suspected MI because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can help reduce chest pain and prevent further damage to the heart muscle. Administering nitroglycerin promptly is crucial in managing an MI. Monitoring cardiac rhythm (B) and assessing the ECG (C) are important steps, but administering nitroglycerin takes precedence in addressing the client's immediate symptoms. Assisting with positioning (D) is not as urgent or directly related to managing an MI compared to administering nitroglycerin.
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Which quadrant of the abdomen is tender in suspected appendicitis?
- A. upper right
- B. upper left
- C. lower right
- D. lower left
Correct Answer: C
Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.
What is the most appropriate action when a parent crosses their arms and legs during an interview?
- A. Just changing positions
- B. More comfortable in this position
- C. Tired and needs a break
- D. Uncomfortable talking about his son's treatment
Correct Answer: D
Rationale: The correct answer is D because crossing arms and legs can indicate defensiveness or discomfort, which may suggest the parent is uneasy discussing their son's treatment. This nonverbal cue could signal a need for empathy and sensitivity in communication. Choice A is incorrect as it overlooks the significance of body language. Choice B assumes comfort without considering the context. Choice C assumes tiredness without considering other possibilities. Understanding body language cues can help in building rapport and addressing concerns effectively.
A nurse is teaching a patient with diabetes about managing blood glucose levels. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood glucose levels regularly.
- B. I will exercise regularly to help manage my condition.
- C. I will stop taking my insulin once my blood glucose is normal.
- D. I will eat a balanced diet and avoid sugary foods.
Correct Answer: C
Rationale: The correct answer is C. Stopping insulin once blood glucose is normal is incorrect as insulin is crucial for managing diabetes even when blood glucose levels are within the target range. Insulin helps regulate blood sugar levels consistently, and stopping it abruptly can lead to hyperglycemia. Choices A, B, and D are correct statements indicating good diabetes management practices. Monitoring blood glucose levels, exercising regularly, and following a balanced diet are essential for controlling blood sugar levels and overall health.
Which fetal heart monitor pattern can indicate cord compression?
- A. variable decelerations
- B. early decelerations
- C. bradycardia
- D. tachycardia
Correct Answer: A
Rationale: The correct answer is A: variable decelerations. Variable decelerations are abrupt decreases in fetal heart rate that vary in depth, duration, and timing, which can indicate cord compression. The variability in these decelerations suggests that the umbilical cord is being compressed intermittently.
Early decelerations (B) are usually caused by head compression during contractions and mirror the contractions, not indicating cord compression. Bradycardia (C) is a slow heart rate, which can be caused by various factors but is not specific to cord compression. Tachycardia (D) is a fast heart rate, which can also be caused by various factors but is not typically associated with cord compression.
What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
- A. Place the client on their back and administer pain medication
- B. Place the client on their side and administer antibiotics
- C. Administer IV fluids and antibiotics
- D. Perform a lumbar puncture
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.