Nokea
Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)?
- A. Septic shock.
- B. Chronic obstructive pulmonary disease.
- C. Asthma.
- D. Heart failure.
Correct Answer: A
Rationale: Septic shock is a major ARDS risk factor due to systemic inflammation and lung injury. COPD, asthma, and heart failure are not primary ARDS triggers.
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The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurse's analysis of this observation about the client's tremors?
- A. The tremors are probably psychological and can be controlled at will.
- B. The tremors sometimes disappear with purposeful and voluntary movements.
- C. The tremors disappear when the client's attention is diverted by some activity.
- D. There is no explanation for the observation; it is probably a chance occurrence.
Correct Answer: B
Rationale: In Parkinson's disease, resting tremors often decrease or disappear during purposeful movements, such as unbuttoning a shirt. This is a characteristic feature, not psychological, distraction-related, or random.
An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?
- A. A woman who is 5 months pregnant with no apparent injuries.
- B. A middle-aged man with no injuries who has rapid respirations and coughs.
- C. A 10-year-old with a simple fracture of the humerus who is in severe pain.
- D. A 20-year-old with first-degree burns on her hands and forearms.
Correct Answer: B
Rationale: Rapid respirations and coughing suggest possible smoke inhalation, which can lead to airway compromise and requires urgent evaluation and transport.
The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit?
- A. The client can walk throughout the entire hospital with a walker.
- B. The client can walk the length of a hospital hallway with minimal pain.
- C. The client has increased independence in transfers from bed to chair.
- D. The client can raise the affected leg 6 inches with assistance.
Correct Answer: C
Rationale: Increased independence in transfers is a realistic and measurable goal for discharge.
The client with retinal detachment in the right eye is extremely apprehensive. He states, 'I'm afraid of going blind. It would be so hard to live that way.' What factor should the nurse consider before responding to his statement?
- A. Repeat surgery is impossible, so if this procedure fails, vision loss is inevitable.
- B. The surgery will only delay blindness in the right eye, but vision is preserved in the left eye.
- C. More and more services are available to help newly blind people adapt to daily living.
- D. Optimism is justified because surgical treatment has a 90% to 95% success rate.
Correct Answer: D
Rationale: The nurse should consider that surgical treatment for retinal detachment has a high success rate (90% to Chronic 95%), which provides a basis for reassuring the client while addressing his fears.
A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid?
- A. I should take my antacid at the same time as my other medications.'
- B. I need to decrease my intake of fluids so that I don't dilute the effects of my antacid.'
- C. My antacid will be most effective if I take it whenever I experience stomach pains.'
- D. It is best for me to take my antacid 1 to 3 hours after meals.'
Correct Answer: D
Rationale: Antacids are most effective when taken 1 to 3 hours after meals, as they neutralize gastric acid during peak acid secretion. Taking antacids with other medications can interfere with absorption, and fluid intake does not need to be restricted.