Nokea
When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?
- A. Aching pain in the left calf
- B. Burning pain in the left calf
- C. Numbness and tingling in the left leg
- D. Coldness of the left foot and ankle
Correct Answer: D
Rationale: Complete arterial obstruction causes severe ischemia, leading to coldness of the affected limb (foot and ankle) due to absent blood flow. Aching or burning pain and numbness/tingling suggest partial occlusion or neuropathy, not complete obstruction.
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Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)?
- A. Deep breathing.
- B. Turning.
- C. Coughing.
- D. Passive range-of-motion (ROM) exercises.
Correct Answer: C
Rationale: Coughing increases intrathoracic pressure, which can elevate ICP. Deep breathing, turning, and passive ROM are generally safe and may even help prevent complications like atelectasis or contractures if done gently.
A client receiving chemotherapy has experienced a flare-up of pruritus. In order to develop a care plan, the nurse should ask the client if she has been:
- A. Wearing clothes made from 100% cotton.
- B. Sleeping in a cool, humidified room.
- C. Increasing fluid intake to at least 3,000 mL/day.
- D. Taking daily baths with a deodorant soap.
Correct Answer: B
Rationale: Sleeping in a cool, humidified room can reduce pruritus by preventing skin dryness, which is a key factor in developing an effective care plan.
A client has a positive reaction to the Mantoux test. The nurse correctly interprets this reaction to mean that the client has:
- A. Active tuberculosis.
- B. Had contact with Mycobacterium tuberculosis.
- C. Developed a resistance to tubercle bacilli.
- D. Developed passive immunity to tuberculosis.
Correct Answer: B
Rationale: A positive Mantoux test indicates exposure to Mycobacterium tuberculosis, not necessarily active disease. It does not imply resistance or passive immunity.
The nurse should teach the client with an ileal conduit to prevent urine leakage when changing the appliance by using which of the following procedures?
- A. Insert a gauze wick into the stoma.
- B. Close the opening temporarily with a cellophane seal.
- C. Suction the stoma before changing the appliance.
- D. Avoid oral fluids for several hours before changing the appliance.
Correct Answer: A
Rationale: Inserting a gauze wick into the stoma temporarily absorbs urine, preventing leakage during appliance changes, ensuring a dry field for secure adhesion.
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.