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When assessing a client reporting severe pain in the right lower quadrant of the abdomen, which sign would most likely indicate appendicitis?
- A. Rebound tenderness at McBurney's point.
- B. Positive Murphy's sign.
- C. Rovsing's sign.
- D. Cullen's sign.
Correct Answer: A
Rationale: The correct answer is A: Rebound tenderness at McBurney's point. McBurney's point is located in the right lower quadrant and is a classic sign of appendicitis. Rebound tenderness at this point indicates inflammation in the peritoneum, suggesting appendicitis. Choices B, C, and D are not specific to appendicitis. Positive Murphy's sign is related to cholecystitis, Rovsing's sign is seen in acute appendicitis but is not as specific as rebound tenderness at McBurney's point, and Cullen's sign is associated with acute pancreatitis.
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A healthcare provider is preparing to administer a scheduled dose of intravenous (IV) metoprolol (Lopressor) to a client. The client's apical pulse is 58 beats/minute. What action should the healthcare provider take?
- A. Administer the medication as prescribed.
- B. Hold the medication and notify the healthcare provider.
- C. Give half the prescribed dose and recheck the pulse in 30 minutes.
- D. Administer the medication and then recheck the pulse in 30 minutes.
Correct Answer: B
Rationale: The correct answer is B: Hold the medication and notify the healthcare provider. The rationale is that metoprolol is a beta-blocker that can further decrease heart rate. With a low apical pulse of 58 beats/minute, administering metoprolol can potentially cause bradycardia or further slow down the heart rate to dangerous levels. Holding the medication and notifying the healthcare provider allows for further assessment and potential adjustment of the dosage or consideration of alternative treatments.
Incorrect choices:
A: Administering the medication as prescribed can lead to bradycardia and potential harm to the client.
C: Giving half the prescribed dose and rechecking the pulse in 30 minutes can still lead to further bradycardia and potential harm.
D: Administering the medication and then rechecking the pulse in 30 minutes is not appropriate as the initial pulse rate is already low, and waiting to recheck could lead to adverse effects before intervention.
In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?
- A. 4+ pitting edema of both lower extremities.
- B. A Braden risk assessment scale rating score of ten.
- C. Warm, dry skin with a fever of 100‚° F.
- D. Hypoactive bowel sounds with infrequent bowel movements.
Correct Answer: B
Rationale: The correct answer is B: A Braden risk assessment scale rating score of ten. This is crucial because the Braden scale assesses the client's risk for developing pressure ulcers. A score of ten indicates a very high risk, requiring frequent repositioning to prevent pressure ulcers.
Choice A is incorrect because 4+ pitting edema of both lower extremities indicates fluid overload, not directly related to turning schedule planning.
Choice C is incorrect because warm, dry skin with a fever of 100‚° F suggests a possible infection, but does not affect the need for turning schedule planning.
Choice D is incorrect as hypoactive bowel sounds and infrequent bowel movements are related to gastrointestinal function, not directly impacting the turning schedule.
When a client expresses, 'I don't know how I will go on' while discussing feelings related to a recent loss, the nurse remains silent. What is the most likely reason for the nurse's behavior?
- A. The nurse is indicating disapproval of the statement.
- B. The nurse is showing respect for the client's loss.
- C. Silence is mirroring the client's sadness.
- D. Silence enables the client to contemplate what was expressed.
Correct Answer: D
Rationale: The correct answer is D because the nurse's silence allows the client to reflect on and process their emotions after expressing uncertainty about the future. By remaining silent, the nurse gives the client space to explore their feelings and thoughts without interruption. This can help the client gain insight and come to terms with their emotions.
A: The nurse's silence does not indicate disapproval, as it is a common therapeutic technique.
B: While the nurse may be showing respect for the client's loss, the primary reason for the silence is to facilitate the client's reflection.
C: Although silence can sometimes mirror the client's emotions, the main purpose here is to enable contemplation rather than direct mirroring.
What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Soft, spongy fundus.
- B. Saturating two perineal pads per hour.
- C. Pulse rate of 56 BPM.
- D. Unilateral lower leg pain.
Correct Answer: C
Rationale: The correct answer is C: Pulse rate of 56 BPM. A normal finding for a primigravida client 12 hours postpartum would be a lower pulse rate as the body is recovering from childbirth. A pulse rate of 56 BPM is within the normal range for an adult.
A: Soft, spongy fundus would be a concerning finding as it could indicate uterine atony.
B: Saturating two perineal pads per hour would be excessive bleeding and could indicate postpartum hemorrhage.
D: Unilateral lower leg pain could be a sign of deep vein thrombosis, which is a potential complication postpartum.
A client with newly diagnosed diabetes mellitus is being discharged home. Which statement indicates the client understands the instructions about managing blood glucose levels?
- A. I will test my blood glucose level once a week.
- B. I should eat a snack if my blood glucose is 70 mg/dl.
- C. If I feel shaky, I should take another dose of insulin.
- D. It's okay to skip a meal if I'm not hungry.
Correct Answer: B
Rationale: The correct answer is B because eating a snack when blood glucose is 70 mg/dl helps prevent hypoglycemia. Testing blood glucose once a week (A) is not frequent enough for proper management. Taking extra insulin when shaky (C) can lead to hypoglycemia. Skipping meals (D) can cause unstable blood glucose levels.