Nokea
An unaccompanied client who is six months pregnant is admitted to the nursing unit with vaginal bleeding.
Which of the following comments, if made by the client, would indicate a need for the nurse to assess the adequacy of the client's emotional support?
- A. My husband will be so angry with me if I lose this baby.
- B. I'm afraid I am going to lose my baby.
- C. I can't stay here. I don't have any insurance.
- D. I feel so guilty. I didn't want to get pregnant.
Correct Answer: A
Rationale: Strategy: Think about what the words mean. (1) correct-client's concern about her husband's feelings indicates that he may not be able to support her emotionally at this time (2) reflects a reality-based concern (3) indicates an economic concern (4) indicates client needs to talk about her current feelings; does not give any indication of level of emotional support
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The nurse is caring for a client with a history of chronic kidney disease.
- A. Which dietary restriction is most important for a client with chronic kidney disease?
- B. Low-sodium diet.
- C. Low-carbohydrate diet.
- D. High-protein diet.
- E. High-fat diet.
Correct Answer: A
Rationale: A low-sodium diet reduces fluid retention and hypertension in chronic kidney disease. Protein is restricted, carbohydrates are encouraged, and high-fat diets are not indicated.
An elderly client is admitted to a skilled nursing care facility. When doing a skin assessment, the nurse notes a 3-cm round area of partial-thickness skin loss that looks like a blister on the client's sacrum. The nurse interprets this to be a:
- A. stage I pressure ulcer.
- B. stage II pressure ulcer.
- C. stage III pressure ulcer.
- D. stage IV pressure ulcer.
Correct Answer: B
Rationale: A stage II pressure ulcer involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer, matching the description. Stage I is non-blanchable erythema, stage III involves full-thickness loss, and stage IV extends to muscle/bone.
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Correct Answer: A
Rationale: Wire cutters are essential for a fractured mandible with wiring, in case of emergency airway obstruction. Oral airway , pliers , and tracheostomy set are not standard.
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
- A. Stand on 1 foot
- B. Catch a ball
- C. Skip on alternate feet
- D. Ride a bicycle
Correct Answer: A
Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.
The nurse is assessing a dark-skinned client with anemia. Which part of the body would the nurse assess for pallor?
- A. Nail beds
- B. Hard palate
- C. Sclera
- D. Buccal mucosa
Correct Answer: D
Rationale: The buccal mucosa is reliable for assessing pallor in dark-skinned clients, as skin pigmentation may mask changes elsewhere.