Nokea
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
- A. Steadily increasing vital signs.
- B. Mild tremors and irritability.
- C. Decreased respirations and disorientation.
- D. Stomach distress and inability to sleep.
Correct Answer: A
Rationale: Steadily increasing vital signs (e.g., heart rate, blood pressure) indicate progression toward delirium tremens, a life-threatening complication of alcohol withdrawal, necessitating additional sedation. Mild tremors, decreased respirations, or gastroinTest inal symptoms are expected or contraindicate more sedation.
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The nurse is caring for a client with a history of chronic venous insufficiency.
- A. Which intervention is most effective for a client with chronic venous insufficiency?
- B. Apply compression stockings.
- C. Encourage bed rest.
- D. Administer diuretics.
- E. Elevate the head of the bed.
Correct Answer: A
Rationale: Compression stockings improve venous return, reducing edema and stasis in chronic venous insufficiency. Bed rest is discouraged, diuretics are not primary, and head elevation is irrelevant.
A 34-year-old multipara comes to the prenatal clinic during her fifth month of pregnancy. The client complains to the nurse that her breasts are sensitive and sore.
Which of the following suggestions by the nurse is BEST?
- A. Apply warm compresses to your breasts and take two aspirin as needed.
- B. Massage your breasts with lotion and wear loose-fitting clothing.
- C. Apply cold compresses to your breasts and wear a well-fitting, supportive bra.
- D. Take a diuretic once a day and avoid touching your breasts.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would increase circulation and increase discomfort, should avoid taking medications (2) not effective in decreasing discomfort (3) correct-during pregnancy there is an increase in lactiferous ducts and lobule-alveolar tissue (4) medications are to be avoided during pregnancy
The client is to be discharged after passing a uric acid kidney stone. This is the third time the client has been hospitalized for kidney stones. The nurse should teach the client to do which of the following?
- A. Eat generous amounts of chicken and organ meats
- B. Drink lots of water
- C. Avoid vigorous activity
- D. Take the ordered allopurinol (Zyloprim) if the symptoms recur
Correct Answer: B
Rationale: Increased fluid intake (lots of water) prevents stone formation by diluting urine. High-purine foods (meats), activity avoidance, or conditional allopurinol are incorrect.
If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
- A. Obtain emergency equipment
- B. Assess heart rate, rhythm and all pulses
- C. Apply pressure to the vessel insertion site
- D. Use cold packs at the exit incision site
Correct Answer: C
Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site to prevent bleeding and complications.
The nurse is caring for a client with a history of multiple sclerosis.
- A. Which symptom is expected in a client with multiple sclerosis?
- B. Chest pain and shortness of breath.
- C. Muscle weakness and spasticity.
- D. Weight gain and edema.
- E. Persistent headaches.
Correct Answer: B
Rationale: Muscle weakness and spasticity are common in multiple sclerosis due to demyelination of nerve fibers. Chest pain, edema, and headaches are not typical symptoms.