Nokea
Which finding on assessment supports the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume?
- A. Flattened neck veins when client is in supine position
- B. Full and bounding pedal and post-tibial pulses
- C. Pitting edema located in feet ankles and calves
- D. Shallow respirations with crackles on auscultation
Correct Answer: A
Rationale: Flattened neck veins in the supine position indicate reduced venous return due to decreased plasma volume, which supports the diagnosis of Decreased Cardiac Output.
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When performing a neurologic assessment on Ken, the physician notices that there is contraction of his facial muscle after tapping the facial nerve anterior to his ear. He recognizes this as Chvostek’s sign. This is seen in:
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hypocalcemia.
- D. Hypomagnesemia.
Correct Answer: C
Rationale: The correct answer is Hypocalcemia (C). Chvostek's sign is a clinical sign of hypocalcemia, where tapping the facial nerve causes twitching of facial muscles due to increased neuromuscular excitability caused by low calcium levels.
A postoperative priority nursing diagnosis for a client having a vertical partial laryngectomy would be:
- A. activity intolerance.
- B. ineffective airway clearance.
- C. high-risk for infection.
- D. an altered oral mucous membrane.
Correct Answer: B
Rationale: The laryngectomy client should be able to gradually increase activities without difficulty. The laryngectomy client may have copious amounts of secretions, which will require suctioning for the first 24-48 hours. Because the mucous collects in the cannula, it will require cleaning after the first 24 hours. Even though the client does have a potential for infection, this is not more important than the ineffective airway clearance. An altered mucous membrane problem is not more important than ineffective airway clearance. The client's mouth may become dry, but can be taken care of with good oral care.
Which statement(s) about older people are only myths and illustrate the concept of ageism (select all that apply)?
- A. Can't teach an old dog new tricks
- B. Old people are not sexually active
- C. Most old people live independently
- D. Most older adults can no longer synthesize new information
Correct Answer: B
Rationale: Statements perpetuating stereotypes about learning ability, sexual activity, and cognitive function in older adults reflect ageism. Many older adults remain capable learners and maintain active lifestyles.
Which of the following describes task-oriented touch?
- A. It is used to demonstrate concern or affection.
- B. It involves the contact required for nursing procedures.
- C. The nurse uses task-oriented touch therapeutically when a client is lonesome.
- D. It involves the touch used for sensory-deprived clients.
Correct Answer: B
Rationale: Task-oriented touch is necessary for performing nursing procedures and ensuring client safety.
Which of the following statements about sexual function in older people is true?
- A. Impotence is an inevitable consequence of aging
- B. Slower arousal and reaction times are normal signs of aging
- C. Moderate alcohol consumption can improve sexual dysfunction
- D. Hormonal replacements are necessary for sexual satisfaction
Correct Answer: B
Rationale: Aging affects sexual function through physiological changes, including slower arousal and response times. However, these changes do not prevent sexual activity entirely.