Nokea
Which client is at highest risk for developing a pressure ulcer?
- A. 23 year-old in traction for fractured femur
- B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
- D. 30 year-old who is comatose following a ruptured aneurysm
Correct Answer: C
Rationale: Risk factors for pressure ulcers include: immobility, absence of
sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence,
increased age, decreased immune response. This client has the greatest number of risk
factors.
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A patient is deciding whether they should take the live influenza vaccine (nasal spray) or the inactivated influenza vaccine (shot). The nurse reviews the client's history. Which condition would NOT contraindicate the nasal (live vaccine) route of administration?
- A. The patient takes long-term corticosteroids
- B. The patient is not feeling well today
- C. The patient is 55 years old
- D. The patient has young children
Correct Answer: D
Rationale: The correct answer is that the patient has young children. Having young children is not a contraindication for the live influenza vaccine unless the children are immunocompromised, which is not mentioned. Choice A, the patient taking long-term corticosteroids, is a contraindication for the live vaccine due to potential immunosuppression. Choice B, the patient not feeling well today, is a general precaution for vaccination and not a contraindication specific to the live influenza vaccine. Choice C, the patient being 55 years old, is not a contraindication for the live vaccine unless there are other specific medical conditions present.
A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
- A. A cerebral vascular accident
- B. Postoperative meningitis
- C. Medication reaction
- D. Metabolic alkalosis
Correct Answer: A
Rationale: The correct answer is a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, including cerebrovascular accidents. Signs and symptoms of a cerebral vascular accident include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures. Postoperative meningitis (choice B) is less likely in this scenario as the sudden onset of seizing is more indicative of a vascular event rather than an infection. Medication reaction (choice C) is not the most probable cause given the history provided. Metabolic alkalosis (choice D) is not associated with sudden seizing in this context.
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
- A. A social worker from the local hospital
- B. An occupational therapist from the community center
- C. A physical therapist from the rehabilitation agency
- D. Another client with diabetes mellitus who takes insulin
Correct Answer: B
Rationale: An occupational therapist from the community center would be the most appropriate referral for this client. Occupational therapists specialize in helping individuals improve fine motor skills, which are essential for tasks like drawing up insulin injections. A social worker typically focuses on psychosocial aspects, a physical therapist on physical mobility, and another client with diabetes would not have the professional expertise to address the client's specific needs related to insulin preparation.
A nurse and client are discussing the client's progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
- A. Pre-interaction
- B. Orientation
- C. Working
- D. Termination
Correct Answer: C
Rationale: The correct answer is the working phase. During this phase, the nurse and client actively work together to explore alternative behaviors and techniques. Discussions in this phase focus on understanding the underlying meaning behind the behavior and implementing strategies for change. Pre-interaction (choice A) refers to the phase before the nurse and client first meet and establish a relationship. The orientation phase (choice B) involves introductions, setting goals, and establishing boundaries. Termination (choice D) is the phase where the therapeutic relationship concludes, and closure is achieved.
Which oxygen delivery system would provide the highest concentrations of oxygen to the client?
- A. Venturi mask
- B. Partial rebreather mask
- C. Non-rebreather mask
- D. Simple face mask
Correct Answer: C
Rationale: The correct answer is the non-rebreather mask. This oxygen delivery system has a one-way valve that prevents exhaled air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent the inhalation of room air but allow exhalation of air. When a tight seal is achieved around the mask, up to 100% of oxygen is available.
Choice A, the Venturi mask, delivers precise oxygen concentrations but not as high as the non-rebreather mask. Choice B, the partial rebreather mask, allows the client to rebreathe some exhaled air, resulting in lower oxygen concentrations than the non-rebreather mask. Choice D, the simple face mask, delivers low to moderate oxygen concentrations and is not designed to provide the highest concentrations like the non-rebreather mask.