Nokea
An older woman hospitalized with a fractured left hip, placed in Buck's traction with a seven-pound weight while awaiting surgery.
Which of the following instructions for moving should be discussed by the nurse to encourage the patient to participate in her care?
- A. Pull up on the overhead trapeze while you push down on your right foot to lift your body.'
- B. With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently.'
- C. I'll raise the head of the bed 45°, and then you lean forward and rotate your hips to the left.'
- D. Swing your right leg over your left leg, and turn from your waist down, keeping your legs straight.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-body must move as single, straight unit (2) turning or twisting from the waist down interferes with countertraction (3) prevents proper pull of weights (4) can't turn from side to side, can only move up and down
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A client is admitted for a series of Test s to verify the diagnosis of Cushing's syndrome.
Which of the following assessment findings, if observed by the nurse, would support this diagnosis?
- A. Buffalo hump, hyperglycemia, and hypernatremia.
- B. Nervousness, tachycardia, and intolerance to heat.
- C. Lethargy, weight gain, and intolerance to cold.
- D. Irritability, moon face, and dry skin.
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to Cushing's syndrome. (1) correct-Cushing's syndrome is characteristic of these assessments, as are weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (2) symptoms of hyperthyroidism (3) symptoms of hypothyroidism (myxedema) (4) symptoms of hypoparathyroidism
The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states, 'I just don't feel good.'
- A. What is the best action for the nurse to take for a client one-day post-angioplasty who refuses to eat and feels unwell?
- B. The nurse talks with the client about how he is feeling.
- C. The nurse instructs the nursing assistant to sit with the client while he eats.
- D. The nurse contacts the physician to obtain an order for an antacid.
- E. The nurse evaluates the most recent vital signs recorded in the chart.
Correct Answer: A
Rationale: Assessment is required to determine the cause of the client’s symptoms, as they could indicate complications such as vessel closure, bleeding, hypotension, or dysrhythmias. Talking with the client to assess current symptoms is the most immediate and appropriate action. Encouraging eating, ordering medication, or reviewing past vital signs does not address the need for current assessment.
A 76-year-old man receiving isoniazid (INH) 200 mg every day for 6 months.
The nurse would be MOST concerned if the client made which of the following statements?
- A. I have blurred vision at times.'
- B. My legs and knees hurt.'
- C. My hands and feet tingle.'
- D. I think I had a migraine yesterday.'
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to Isoniazid. (1) infrequent side effect of the medication (2) not a side effect of the medication (3) correct-may cause peripheral neuropathy indicated by tingling, may also see nausea (4) not a side effect of the medication
When teaching a client about an oral hypoglycemic medication, the nurse should place primary emphasis on
- A. recognizing findings of toxicity
- B. taking the medication at specified times
- C. increasing the dosage based on blood glucose
- D. distinguishing hypoglycemia from hyperglycemia
Correct Answer: B
Rationale: A regular interval between doses should be maintained since oral hypoglycemics stimulate the islets of Langerhans to produce insulin.
The nurse is inserting an indwelling urinary catheter in an adult woman. The nurse locates landmarks before inserting the catheter. The urethral opening is located:
- A. above the clitoris.
- B. behind the vagina.
- C. between the clitoris and the vagina.
- D. between the vagina and the rectum.
Correct Answer: C
Rationale: The female urethral opening is located between the clitoris and vagina, a key landmark for catheter insertion to avoid incorrect placement.