Nokea
Which instructions should the nurse discuss with the client diagnosed with Raynaud's phenomenon?
- A. Explain that exacerbations will not occur in the summer
- B. Use nicotine gum to help quit smoking
- C. Wear extra warm clothing during cold exposure
- D. Avoid prolonged exposure to direct sunlight
Correct Answer: C
Rationale: The correct instruction for a client diagnosed with Raynaud's phenomenon is to wear extra warm clothing during cold exposure. This is essential in preventing vasospasms triggered by cold temperatures, which can worsen symptoms of Raynaud's phenomenon. Choice A is incorrect because exacerbations can occur in any season. Choice B is irrelevant and not directly related to managing Raynaud's phenomenon. Choice D is also incorrect as sunlight exposure does not significantly impact Raynaud's phenomenon.
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A patient is prescribed an oral anticoagulant. What should the nurse monitor for?
- A. Elevated blood glucose
- B. Decreased blood pressure
- C. Signs of bleeding
- D. Increased appetite
Correct Answer: C
Rationale: Correct! When a patient is prescribed an oral anticoagulant, the nurse should monitor for signs of bleeding. Oral anticoagulants are medications that prevent blood clot formation but can increase the risk of bleeding. Monitoring for signs such as easy bruising, blood in urine or stool, and prolonged bleeding from minor cuts is essential. Choices A, B, and D are incorrect because oral anticoagulants do not typically affect blood glucose levels, blood pressure, or appetite.
Participating in the development of long-term and preventive health goals with the patient and their family is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: B
Rationale: The correct answer is B: Planning. Planning in nursing care involves setting long-term and preventive goals for the patient in collaboration with the patient and their family. This step ensures that a comprehensive and individualized care plan is developed. Choice A, Evaluation, comes after the interventions have been implemented to assess their effectiveness. Choice C, Implementation, is the step where the care plan is put into action. Choice D, Assessment, is the initial step that involves collecting data to identify the patient's needs, which is done before planning the care.
The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client's neurological status should include which of the following? (Select all that apply)
- A. Obtain the pulses in all four extremities
- B. Ask the client to grasp and squeeze two fingers on each of the nurse's hands
- C. Determine the client's orientation to person, place, and time
- D. B, C
Correct Answer: D
Rationale: The correct answer is 'D' because assessing grasp strength (choice B) and orientation to person, place, and time (choice C) are crucial components of a neurological assessment following a cerebrovascular accident (CVA). Pulse assessment in all four extremities (choice A) is not directly related to a neurological assessment and is more pertinent to vascular status. Therefore, choices A and D are incorrect in this context.
When measuring the leg circumference of a client with bipedal edema, what position is best to ensure accurate measurements?
- A. Dorsal recumbent
- B. Sitting
- C. Standing
- D. Supine
Correct Answer: A
Rationale: When measuring the leg circumference of a client with bipedal edema, the best position to ensure accurate and consistent measurements is the dorsal recumbent position. This position allows the legs to be positioned comfortably, and the individual is lying on their back with legs extended, facilitating accurate measurement of the circumference without the influence of gravity. Sitting, standing, and supine positions may not provide optimal conditions for accurate leg circumference measurements, particularly in clients with bipedal edema where positioning and consistency are crucial. Sitting and standing positions may not allow for consistent leg positioning and could introduce errors due to the effects of gravity on the fluid distribution. The supine position, while similar to dorsal recumbent, may not be as comfortable for the client and could still be influenced by gravity when measuring leg circumference.
The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?
- A. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor
- B. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes
- C. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk
- D. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress
Correct Answer: C
Rationale: The correct method described in option C helps maintain spinal alignment while moving from a lying to a standing position, which is crucial after a lumbar laminectomy with spinal fusion. This technique minimizes strain on the back and promotes safe movement. Choices A, B, and D involve movements that could potentially strain the back, increase the risk of injury, or compromise the spinal alignment, making them less optimal for the client recovering from such surgery.