Nokea
What term describes excessive stretching of a ligament, as seen in a client with a pulled ligament?
- A. sprain
- B. strain
- C. subluxation
- D. distortion
Correct Answer: B
Rationale: The correct answer is B: strain. A strain refers to excessive stretching or tearing of a muscle or tendon, not a ligament. A sprain (choice A) is the correct term for excessive stretching of a ligament. Subluxation (choice C) refers to partial dislocation of a joint, not a ligament injury. Distortion (choice D) is a general term that does not specifically describe ligament stretching. Therefore, the correct term for excessive stretching of a ligament is a sprain, making choice A the correct answer.
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What should be the nurse's first action for a client who has sustained a spinal cord injury?
- A. Immobilize the spine
- B. Assess the client's airway
- C. Place the client in a supine position
- D. Encourage deep breathing
Correct Answer: C
Rationale: The correct answer is C: Place the client in a supine position. This is the first action because it helps prevent further injury to the spinal cord by maintaining alignment. Immobilizing the spine (choice A) is important but should come after placing the client in a supine position. Assessing the client's airway (choice B) is crucial but not the first action in a spinal cord injury. Encouraging deep breathing (choice D) is not appropriate as the priority is to stabilize the spine. In summary, placing the client in a supine position is the initial step to prevent worsening of the spinal cord injury, while the other choices are important but secondary actions.
What is the first step in the care of a client with a severe allergic reaction?
- A. Administer epinephrine
- B. Administer corticosteroids
- C. Administer corticosteroids
- D. Apply a cold compress
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. This is the first step in the care of a client with a severe allergic reaction because epinephrine is the primary medication used to reverse the life-threatening symptoms of anaphylaxis. Epinephrine acts quickly to constrict blood vessels, relax smooth muscles in the lungs to improve breathing, and increase heart rate. Administering epinephrine promptly can prevent progression to severe outcomes like respiratory failure or shock. Corticosteroids (B and C) are used as adjunct therapy and do not provide immediate relief. Applying a cold compress (D) does not address the systemic effects of anaphylaxis and can delay potentially life-saving treatment.
A nurse is caring for a patient with diabetes who is experiencing diabetic neuropathy. The nurse should educate the patient to prioritize which of the following?
- A. Inspecting feet daily for signs of injury.
- B. Exercising to increase circulation.
- C. Taking pain medication for relief.
- D. Increasing protein intake to support healing.
Correct Answer: A
Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial in diabetic neuropathy to prevent complications such as infections and ulcers. By inspecting the feet daily, the patient can identify any injuries early and seek prompt treatment. Exercising (choice B) is important, but not the top priority. Taking pain medication (choice C) only addresses symptoms, not the root cause. Increasing protein intake (choice D) may be beneficial for healing, but foot inspection is more directly related to preventing complications in diabetic neuropathy.
A nurse is caring for a patient with diabetes and peripheral neuropathy. The nurse should educate the patient to prioritize which of the following?
- A. Inspecting feet daily for signs of injury.
- B. Engaging in weight-bearing exercise.
- C. Increasing protein intake.
- D. Using tight-fitting shoes.
Correct Answer: A
Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for a patient with diabetes and peripheral neuropathy to prevent complications like diabetic foot ulcers. Daily foot inspections can help detect any injuries or changes early to prevent infection or further damage. It is important to prioritize this over other choices because early intervention can prevent serious consequences. Engaging in weight-bearing exercise (choice B) can be beneficial but may not be the priority in this case. Increasing protein intake (choice C) is not directly related to foot care. Using tight-fitting shoes (choice D) can lead to pressure ulcers and should be avoided.
What is the priority action for a client who presents with symptoms of stroke?
- A. Perform a CT scan
- B. Monitor blood pressure
- C. Administer aspirin
- D. Administer thrombolytics
Correct Answer: A
Rationale: The correct answer is A: Perform a CT scan. This is the priority action because it helps determine if the stroke is ischemic or hemorrhagic, guiding treatment decisions. Monitoring blood pressure (B) is important but not the priority. Administering aspirin (C) can be considered after confirming the type of stroke. Administering thrombolytics (D) is indicated for ischemic stroke but should only be done after ruling out hemorrhagic stroke with a CT scan.