Nokea
Which activity should a client with an ileal conduit avoid?
- A. Swimming.
- B. Walking.
- C. Heavy lifting.
- D. Reading.
Correct Answer: C
Rationale: Heavy lifting can strain the stoma site, increasing hernia risk.
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Which of the following has been identified as a potential risk factor for the development of colon cancer?
- A. Chronic constipation.
- B. Long-term use of laxatives.
- C. History of smoking.
- D. History of inflammatory bowel disease.
Correct Answer: D
Rationale: A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet. CN: Reduction of risk potential; CL: Analyze
The nurse is assessing a client with chronic pain. Which of the following is an expected response?
- A. Elevated vital signs, physical inactivity, facial grimacing, and periods of anxiety.
- B. Normal vital signs, physical inactivity, and unusual physical sensitivity.
- C. Normal vital signs, normal facial expressions, and moaning.
- D. Elevated vital signs, grimacing, and depression.
Correct Answer: B
Rationale: Chronic pain often results in normal vital signs (due to adaptation), physical inactivity (to avoid pain), and unusual physical sensitivity, as patients may guard or protect painful areas.
A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased: decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first?
- A. Encourage the client to drink at least 1,000 mL per day.
- B. Provide parenteral rehydration therapy ordered by the physician.
- C. Turn and reposition every 2 hours.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: The client's symptoms indicate dehydration, requiring immediate parenteral rehydration therapy as ordered to restore fluid balance. Oral fluids, repositioning, or monitoring are less urgent or inappropriate as the first action. CN: Physiological adaptation; CL: Synthesize
The nurse uses a Doppler ultrasound device to assess the client's lower extremities. In addition, the nurse calculates the ankle-brachial index to estimate stenosis of the:
- A. Arteries
- B. Aorta
- C. Carotid
- D. Veins
Correct Answer: A
Rationale: The ankle-brachial index (ABI) measures the ratio of ankle to brachial systolic blood pressure to assess arterial stenosis in the lower extremities. A low ABI indicates arterial narrowing, typical in PVD. It does not assess the aorta, carotid, or veins.
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)?
- A. Double vision.
- B. Sudden bursts of energy.
- C. Weakness in the extremities.
- D. Muscle tremors.
Correct Answer: B
Rationale: Sudden bursts of energy are not typical in MS, which often causes fatigue. Double vision, weakness, and tremors are common due to demyelination affecting vision, motor, and coordination.