Nokea
Which of the following information should the nurse include?
- A. Return in two weeks for a follow up MRI - MRI should be avoided
- B. Expect to have a rapid pulse rate for the first few weeks?
- C. Resume tub baths and swimming after 24hr
- D. Wear loose fitting clothing
Correct Answer: D
Rationale: The correct answer, D, "Wear loose fitting clothing," is important post-surgery to prevent constriction on the surgical site and promote healing. Tight clothing can lead to increased pain and delayed recovery. Choice A is incorrect as MRI should be avoided post-surgery due to potential interference with healing. Choice B is incorrect as a rapid pulse rate is not a typical expectation post-surgery. Choice C is incorrect as tub baths and swimming should be avoided to prevent infection.
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Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
- A. Confusion
- B. Increased thirst
- C. Frequent urination
- D. Flushed skin
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is a condition characterized by low blood sugar levels, leading to symptoms like confusion due to the brain not receiving enough glucose for energy. Increased thirst and frequent urination are more indicative of hyperglycemia (high blood sugar levels). Flushed skin is not a common manifestation of hypoglycemia.
After reviewing the discharge instructions with the family, which of the following statements by a parent indicate an understanding of the teaching? Click to specify if the statement reflects an understanding or indicates a need for reinforcement.
- A. We should notify the provider if the cast becomes loose over time.
- B. It is important that our child avoids placing anything inside the cast.
- C. We should prop the casted arm on pillows for the next 24 hours.
- D. We should expect the swelling and tingling to worsen before it gets better.
- E. We need to be very careful about how we handle the cast for the first 2 days while it dries.
Correct Answer: A,B,C,E
Rationale: Statements A, B, C, and E reflect correct understanding. Expecting worsening symptoms (D) requires clarification as it may indicate complications.
The nurse should expect the adolescent to be in which of the following of erikson stages of psychosocial development.
- A. Identity versus role confusion
- B. Autonomy versus shame and doubt
- C. Initiative versus guilt
- D. Intimacy versus isolation
Correct Answer: A
Rationale: The correct answer is A: Identity versus role confusion. During adolescence, individuals are in Erikson's stage of developing a sense of identity and may struggle with role confusion. This stage typically occurs during the teenage years, where adolescents are exploring their personal values, beliefs, and goals. They are trying to establish a sense of self and may question their identity and place in the world. Choices B, C, and D are incorrect because Autonomy versus shame and doubt relates to toddlers, Initiative versus guilt relates to preschoolers, and Intimacy versus isolation relates to young adults. This makes A the most appropriate choice for an adolescent's stage of psychosocial development.
A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up?
- A. Potassium level
- B. Breath sounds
- C. WBC count
- D. Temperature
- E. Blood pressure
Correct Answer: C,D
Rationale: Decreased WBC count and elevated temperature suggest infection, requiring follow-up. Potassium levels remain within normal range, so no action is needed.
Select the findings that indicate the interventions have been effective.
- A. Client rates pain with contractions as a 3 on a scale of 0 to 10
- B. Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds
- C. Accelerations present, no decelerations noted
- D. Heart rate 88/min
- E. Blood pressure 122/80 mm Hg
- F. Temperature 38° C(100.4° F)
Correct Answer: A,C
Rationale: Effective pain relief (client rates pain as 3) and normal FHR patterns indicate successful interventions.