Nokea
Which nursing intervention promotes achievement of the goal 'optimal mobility' for a client who had a total hip replacement 8 hours ago?
- A. Encourage the client to use an abductor pillow when ambulating.
- B. Teach the client to perform leg exercises in bed.
- C. Assist the client to sit at the edge of the bed.
- D. Assist the client to turn while an abductor pillow is between the legs.
Correct Answer: D
Rationale: Assisting the client to turn while an abductor pillow is between the legs is the correct intervention to promote optimal mobility for a client who had a total hip replacement 8 hours ago. Using an abductor pillow helps maintain hip alignment and prevents dislocation, which are crucial considerations in the early postoperative period. Encouraging the client to use an abductor pillow when turning is more beneficial compared to the other options: teaching leg exercises in bed, encouraging the use of a walker when ambulating, or assisting the client to sit at the edge of the bed, as these interventions may not directly address the specific needs of a client after a total hip replacement.
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A woman with chronic osteoarthritis is complaining of knee pain. Which pathophysiological process is contributing to her pain?
- A. Inflammation of the synovial membrane.
- B. Degeneration of the cartilage in the joint.
- C. Joint inflammation occurs when chondrocyte injury destroys joint cartilage, producing osteophytes.
- D. Formation of uric acid crystals in the joint space.
Correct Answer: C
Rationale: The correct answer is C. In osteoarthritis, the breakdown of cartilage in the joints leads to chondrocyte injury, which results in the destruction of joint cartilage and the production of osteophytes. This process causes joint inflammation and pain. Choice A is incorrect because osteoarthritis primarily involves the articular cartilage rather than the synovial membrane. Choice B is incorrect as it describes the degeneration of cartilage but does not explain the specific pathophysiological process contributing to pain in osteoarthritis. Choice D is incorrect as the formation of uric acid crystals is characteristic of gout, not osteoarthritis.
A young client who is being taught how to use an inhaler for symptoms of asthma tells the nurse about the intention to use the inhaler but plans to continue smoking cigarettes. In evaluating the client's response, what is the best initial action by the nurse?
- A. Explain the risks of smoking with asthma.
- B. Revise the plan of care.
- C. Encourage the client to reduce smoking gradually.
- D. Provide resources for smoking cessation.
Correct Answer: B
Rationale: The best initial action by the nurse is to revise the plan of care. This is necessary to address the client's intention to continue smoking and ensure that appropriate support and education are provided. Choice A is not the best initial action as the client is already aware of the risks of smoking with asthma. Choice C might not be effective as the client's intention to continue smoking poses a significant risk to their health. Choice D, providing resources for smoking cessation, is important but revising the plan of care should come first to address the immediate concern.
What is a causative factor of Hirschsprung disease?
- A. Frequent evacuation of solids, liquid, and gases
- B. Excessive peristaltic movement
- C. The absence of parasympathetic ganglion cells in a portion of the colon
- D. One portion of the bowel telescoping into another
Correct Answer: C
Rationale: The correct answer is C: The absence of parasympathetic ganglion cells in a portion of the colon is a causative factor of Hirschsprung disease. This absence leads to the inability of the affected segment of the colon to relax, causing a functional obstruction. Choices A, B, and D are incorrect. Frequent evacuation of solids, liquid, and gases, excessive peristaltic movement, and one portion of the bowel telescoping into another are not causative factors of Hirschsprung disease.
The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply)
- A. Abdominal obesity
- B. Blood pressure of 150/96 mmHg
- C. Increased triglyceride levels
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, as all the listed factors - abdominal obesity, high blood pressure, and increased triglyceride levels - are components of metabolic syndrome. Addressing these findings is crucial to help reduce the client's risk for developing diabetes mellitus and vascular disease. Abdominal obesity is a key feature of metabolic syndrome, high blood pressure (150/96 mmHg) is a risk factor, and increased triglyceride levels are also indicative of the syndrome. Educating the client on lifestyle modifications, such as healthy eating habits, regular physical activity, and monitoring these parameters, is essential in managing metabolic syndrome and preventing associated complications. Choices A, B, and C are all correct, making choice D the correct answer.
The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of four congenital defects. What are the defects?
- A. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
- B. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
- C. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy
- D. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
Correct Answer: B
Rationale: The correct answer is B: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. Tetralogy of Fallot involves these four congenital defects. Choice A is incorrect because it includes aortic stenosis instead of pulmonary stenosis, atrial septal defect instead of ventricular septal defect, and left ventricular hypertrophy instead of right ventricular hypertrophy. Choice C is incorrect as it includes aortic stenosis and atrial septal defect instead of pulmonary stenosis and ventricular septal defect. Choice D is incorrect because it includes aortic hypertrophy instead of overriding aorta.