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Which of the ff actions should the nurse perform before a client with impaired physical mobility gets up?
- A. Use parallel bars or a walker
- B. Use incontinence pads
- C. Apply an abdominal binder
- D. Use a footboard
Correct Answer: A
Rationale: Before a client with impaired physical mobility gets up, the nurse should ensure that the appropriate assistive device is available and properly set up for the client to use. Using parallel bars or a walker provides support and stability, helping the client maintain balance and prevent falls while standing and walking. This would be the most suitable action to take before assisting the client in getting up to ensure their safety and mobility. Applying incontinence pads, an abdominal binder, or using a footboard are not directly related to the immediate need of assisting the client with impaired physical mobility in getting up.
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Calcium carbonate is given with meals to a child with chronic renal disease. What is the purpose of administering calcium carbonate?
- A. Prevent vomiting
- B. Bind phosphorus
- C. Stimulate appetite
- D. Increase absorption of fat-soluble vitamins
Correct Answer: B
Rationale: In chronic renal disease, the kidneys are not functioning properly, leading to an accumulation of phosphorus in the body. High levels of phosphorus can be harmful and contribute to bone and mineral disorders. Calcium carbonate is often given with meals to bind phosphorus in the gut and prevent its absorption. By binding with phosphorus, calcium carbonate helps lower the levels of phosphorus in the blood, thereby managing complications associated with chronic renal disease, such as renal osteodystrophy. It is an essential part of the treatment plan for patients with chronic kidney disease to help maintain appropriate phosphorus balance in the body and prevent further complications.
The presence of anemia is characterized by a/an:
- A. Increase of red blood cells
- B. Increased hemoglobin
- C. Decrease in the concentration of red blood
- D. Decreased blood count cells
Correct Answer: C
Rationale: Anemia is a condition characterized by a decrease in the concentration of red blood cells in the blood. This can result from various factors such as decreased production of red blood cells, increased destruction of red blood cells, or blood loss. Hemoglobin levels are often used to diagnose anemia, but the key feature of anemia is the decrease in the number of red blood cells, leading to reduced oxygen-carrying capacity in the blood. This in turn can lead to symptoms such as fatigue, weakness, and shortness of breath.
When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
- A. Bend forward at the waist with arms hanging freely.
- B. Lie flat on the floor and extend her legs straight from the trunk.
- C. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
- D. Stand against a wall while pressing the length of her back against the wall.
Correct Answer: A
Rationale: When assessing a female adolescent for scoliosis, the nurse should ask the client to bend forward at the waist with arms hanging freely. This Adams forward bend test allows the nurse to evaluate the spine for any asymmetry, curvature, or rib hump that may indicate scoliosis. By observing the alignment of the spine while the client is in a forward bent position, the nurse can gather important information to determine if further evaluation or referral to a healthcare provider is necessary.
A patient visits her nurse practitioner (NP) after she has a cold for a week and is now experiencing a severe headache and fever. Her NP diagnoses a sinus infection. Which of the following additional symptoms is the patient likely to exhibit?
- A. Facial tenderness
- B. Photophobia
- C. Chest pain
- D. Ear drainage
Correct Answer: A
Rationale: Sinus infections, also known as sinusitis, are often characterized by symptoms such as congestion, facial pain or pressure, and nasal discharge. Facial tenderness over the affected sinuses, particularly when tapping on the area, is a common symptom associated with sinus infections due to the inflammation and buildup of mucus in the sinuses. This tenderness is often present in the cheeks, forehead, or around the eyes. The other symptoms mentioned in the choices (photophobia, chest pain, ear drainage) are less commonly associated with sinus infections compared to facial tenderness.
Which of the ff nursing interventions should a nurse perform when caring for a client with congestive heart failure who has decreased cardiac output?
- A. Encourage activities that engage the Valsalva maneuver
- B. Encourage the client to perform exercises
- C. Assess apical heart before administering digitalis
- D. Offer small frequent feedings
Correct Answer: C
Rationale: Decreased cardiac output is a serious concern in clients with congestive heart failure. By assessing the apical heart rate before administering digitalis, the nurse can monitor the client's cardiac status and prevent possible complications such as digitalis toxicity. Digitalis is a medication commonly used to improve cardiac output in clients with heart failure, but it can also cause harm if given inappropriately, especially if the client's heart rate is already low. Monitoring the client's apical heart rate before giving digitalis helps ensure that the medication is safely administered and that the client's cardiac status is closely monitored. This intervention is crucial in the care of clients with congestive heart failure to optimize patient safety and outcomes.