Nokea
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria occurs in right-sided heart failure due to fluid redistribution at night. Shortness of breath and crackles are more typical of left-sided failure. Oliguria is not specific.
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An adult man believes that someone is poisoning his food. What is the best nursing action in response to this belief?
- A. Explain to him that no one is poisoning his food
- B. Tell him that the food is prepared in the hospital under secure conditions
- C. Taste his food to assure him that it is not being poisoned
- D. Offer him food that is in individual containers
Correct Answer: D
Rationale: Offering individually packaged food addresses the delusion non-confrontationally, reducing anxiety. Explaining, assuring, or tasting may escalate distrust.
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: The resistant bacteria remain alive for up to 3 days after the client dies. Therefore, contact precautions must still be implemented.
A client with a twenty-five-year history of alcohol abuse is seen in the outpatient clinic for treatment of chronic cirrhosis.
Which of the following symptoms would suggest to the nurse that the client is in the early stages of hepatic encephalopathy?
- A. The patient's abdomen is distended with a protruding umbilicus.
- B. The patient has difficulty describing what he does at work.
- C. The patient's respirations are 32, and he appears to be drowsy.
- D. The patient's upper extremities are adducted, and his lower extremities are internally rotated.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to hepatic encephalopathy. (1) ascites is symptom of cirrhosis (2) correct-impaired thought processes is early symptom (3) hyperventilation and stupor is late symptom (4) decerebrate/decorticate posturing late symptom
The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except:
- A. disclose the information before the child knows or suspects.
- B. be comfortable with your sexual preference first.
- C. have the discussion in a quiet place where interruptions are unlikely.
- D. explain how your relationship with the child changes because of the discussion.
Correct Answer: D
Rationale: Children of gay and lesbian parents should be reassured that their relationship with their parent will not change because of the discussion.
A client is scheduled for a myelogram at the outpatient clinic.
Which of the following statements, if made by the nurse, correctly describes a myelogram?
- A. The Test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown.'
- B. The Test involves injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk.'
- C. The Test involves a lumbar puncture with injection of contrast medium, allowing accettare visualization of the vertebral canal.'
- D. The Test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space.'
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a myelogram. (1) x-ray examination cannot determine the extent of myelin breakdown (2) no such procedure (3) correct-contrast medium or air is injected into spinal subarachnoid space through a spinal puncture, identifies tumors, cysts, herniated vertebral discs (4) no such procedure