Nokea
Which neurological complication can occur when a vest restraint is too tight around the client's body?
- A. Strangulation
- B. Skin breakdown
- C. Skin pallor
- D. Numbness
Correct Answer: A
Rationale: A too-tight vest restraint can cause strangulation, a life-threatening complication, by restricting breathing or neck movement.
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The nurse is assisting a primary health care provider with abdominal paracentesis. What position should the nurse assist the client into for this procedure?
- A. Prone
- B. Supine
- C. Semi-Fowler's on the back
- D. Low Fowler's on the right side
Correct Answer: C
Rationale: For abdominal paracentesis, the nurse should position the client in either a semi-Fowler's position or an upright position on the edge of the bed with the feet resting on a stool and the back well supported. This position allows the intestine to float posteriorly and helps prevent laceration during catheter insertion. None of the remaining options suggest the correct position.
A client has polycystic kidney disease. The client asks the nurse, 'How did I get these fluid-filled bubbles on my kidneys? I have not had any X-ray type tests.' How should the nurse respond to help the client understand risk factors for this disease process?
- A. Second-hand smoke puts you at greater risk for developing cysts.'
- B. Exposure to dyes used to color fruits and vegetables increases the risk of polycystic kidney disease.'
- C. There is a higher incidence of polycystic kidney disease among blood relatives.'
- D. Drinking alcohol daily allows the kidneys to develop cysts.'
Correct Answer: C
Rationale: Polycystic kidney disease is primarily genetic, with a higher incidence among blood relatives due to autosomal dominant or recessive inheritance patterns.
One of the primary purposes of a formal medication reconciliation is to:
- A. Prevent polypharmacy
- B. Conserve financial resources
- C. Prevent interactions
- D. Prevent allergies
Correct Answer: C
Rationale: Medication reconciliation compares current and previous medication lists to identify and prevent potential drug interactions, ensuring safe prescribing.
A client with a history of cirrhosis is admitted with ascites. The nurse should include which of the following in the plan of care?
- A. Administer spironolactone as prescribed.
- B. Restrict sodium intake.
- C. Encourage a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A, B
Rationale: Spironolactone and sodium restriction reduce fluid retention in ascites.
During a clinic visit for a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best?
- A. The hormonal changes your body is experiencing are causing you to feel this way.'
- B. Most new mothers feel the same way that you do. I hear that a lot from others.'
- C. You need to have your husband and family help you so that you can get some rest.'
- D. I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling.'
Correct Answer: D
Rationale: Acknowledging the mother's feelings and encouraging her to elaborate promotes therapeutic communication and helps assess for postpartum depression or other concerns. Attributing feelings solely to hormones, normalizing without exploration, or suggesting family help without assessment may miss underlying issues.