Nokea
Which of the following impacts on the client's preferences in terms of hygiene routines and practices?
- A. Culture
- B. Locus of control
- C. Bodily surface area
- D. Diaphoresis
Correct Answer: A
Rationale: Culture significantly influences hygiene preferences, as beliefs and practices vary widely across cultural groups.
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Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
- A. Polyuria, nausea, and severe headaches
- B. Polydipsia, translucent skin, and obesity
- C. Fever, tachycardia, and systolic hypertension
- D. Profuse diaphoresis, flushing, and constipation
Correct Answer: C
Rationale: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.
The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
- A. Can you describe what the pain feels like?
- B. Can you rate the pain on a scale of 1 to 10 ?
- C. Did you get any relief from the last dose of pain medication?
- D. Can you compare this pain to the pain you felt before surgery?
Correct Answer: D
Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Standard pain assessment techniques also include the items described in the remaining options, but these will not help differentiate current pain from preoperative pain.
A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge?
- A. I will implement my exercise program as soon as I get home.'
- B. I will be careful not to cross my legs.'
- C. I will need an elevated toilet seat.'
- D. I can't wait to take a tub bath when I get home.'
Correct Answer: D
Rationale: Tub baths are contraindicated post-hip replacement due to the risk of hip flexion beyond 90 degrees, indicating a need for further teaching.
The nurse is teaching a client with a new diagnosis of hypertension about the DASH diet. Which of the following foods should the nurse recommend?
- A. White bread.
- B. Bananas.
- C. Sausage.
- D. Potato chips.
Correct Answer: B
Rationale: Bananas are rich in potassium and part of the DASH diet, which promotes heart-healthy eating to manage hypertension.
Pelvic inflammatory disease is most often caused by:
- A. Trichomoniasis
- B. E. coli
- C. Staphylococcus aureus
- D. Neisseria gonorrhoeae
Correct Answer: D
Rationale: Neisseria gonorrhoeae is a common cause of pelvic inflammatory disease, often resulting from untreated gonorrhea, leading to infection of the reproductive organs.