Nokea
Which assessment finding would most likely indicate that a client has thrombophlebitis in the leg?
- A. Diminished pedal pulses
- B. Color changes in the extremities when elevated
- C. Red, shiny skin
- D. Coolness and pallor in the leg
Correct Answer: C
Rationale: Red, shiny skin is a common sign of thrombophlebitis due to inflammation and impaired venous return. Diminished pulses, color changes with elevation, or coolness are more indicative of arterial issues.
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A prothrombin time test should be performed regularly on persons who are taking which medication?
- A. Heparin
- B. Warfarin
- C. Phenobarbital
- D. Digoxin
Correct Answer: B
Rationale: A prothrombin time test is done to determine the effectiveness of warfarin. A partial thromboplastin time test is used for heparin. Phenobarbital and digoxin do not require regular clotting tests, though serum levels may be monitored for long-term therapy.
The nurse understands that the client's hesitation in going to the hospital is an example of which coping mechanism?
- A. Regression
- B. Projection
- C. Denial
- D. Undoing
Correct Answer: C
Rationale: Denial involves minimizing or ignoring symptoms, such as attributing chest pain to muscle strain, delaying medical care.
Which response by the nurse is most appropriate at this time?
- A. What are your concerns?
- B. Why are you so scared?
- C. Your doctor says you are doing just fine.
- D. You need to concentrate on getting well.
Correct Answer: A
Rationale: Asking about concerns encourages the client to express fears, facilitating emotional support and reducing anxiety.
As part of the discharge instructions, the nurse correctly instructs the client that which symptom is a sign of artificial pacemaker malfunction?
- A. Tingling in the chest area
- B. Dizziness during activity
- C. Pain radiating to the arm
- D. Tenderness beneath the skin
Correct Answer: B
Rationale: Dizziness during activity may indicate pacemaker failure to maintain adequate heart rate.
Having heard the observer's comment, which statement by the nurse would be most helpful for an untrained individual to remember if a trained individual is not present?
- A. An untrained person can always stay with the victim until help arrives.
- B. Do not worry about compressions; just breathe regularly in the mouth.
- C. Begin chest compressions in the center of the chest pressing down 2 inches (5 cm).
- D. Place the client flat and elevate the feet to promote circulation.
Correct Answer: C
Rationale: Untrained individuals can perform compression-only CPR, pressing 2 inches deep at 100-120 per minute.