Nokea
Which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease?
- A. 45-year-old mother.
- B. 17-year-old daughter.
- C. 8-year-old son.
- D. 76-year-old grandmother.
Correct Answer: D
Rationale: The elderly (76-year-old grandmother) are at highest risk due to weakened immune systems, increasing susceptibility to tuberculosis infection. Children and younger adults are less vulnerable unless immunocompromised.
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The client asks the nurse, 'Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?' On which of the following should the nurse base the response?
- A. The need to remove as much of the leg as possible.
- B. The adequacy of the blood supply to the tissues.
- C. The ease with which a prosthesis can be fitted.
- D. The client's ability to walk with a prosthesis.
Correct Answer: B
Rationale: The extent of amputation depends on tissue viability, determined by blood supply intraoperatively.
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) accurately reflects the client's rapid tiring due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported by the symptoms described.
After an inguinal herniorrhaphy, the nurse should assess the client carefully for which of the following likely complications?
- A. Pneumonia.
- B. Deep vein thrombosis.
- C. Paralytic ileus.
- D. Urine retention.
Correct Answer: D
Rationale: Urine retention is a likely complication after inguinal herniorrhaphy due to anesthesia, pain, or surgical manipulation near the bladder. Pneumonia, deep vein thrombosis, and paralytic ileus are less specific to this surgery. CN: Physiological adaptation; CL: Analyze
If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe?
- A. Oliguria.
- B. Bradycardia.
- C. Elevated blood pressure.
- D. Fever.
Correct Answer: A
Rationale: Cardiogenic shock causes decreased cardiac output, leading to reduced renal perfusion and oliguria (low urine output). Bradycardia, elevated BP, and fever are not typical signs.
The nurse finds an unlicensed assistive personnel massaging the reddened bony prominences of a client on bed rest. The nurse should:
- A. Reinforce the aide's use of this intervention over the bony prominences.
- B. Explain that massage is effective because it improves blood flow to the area.
- C. Inform the aide that massage is even more effective when combined with lotion during the massage.
- D. Instruct the aide that massage is contraindicated because it decreases blood flow to the area.
Correct Answer: D
Rationale: Massaging reddened bony prominences is contraindicated, as it can damage fragile tissue and reduce blood flow, worsening the risk of pressure ulcers.