Nokea
A client chief complaint in a nursing health history.
Which of the following is an example of a properly recorded client chief complaint in a nursing health history?
- A. Complains of midepigastric discomfort with flatus after meals.'
- B. Area above umbilicus appears to be painful and tender to palpation.'
- C. My stomach hurts after dinner every night.'
- D. Rebound tenderness present in mid-to-upper abdominal area.'
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) incorrectly stated (2) objective finding (3) correct-chief complaint should be recorded using the client's own words (4) objective finding
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The nurse is caring for a client with a history of chronic venous insufficiency.
- A. Which intervention is most effective for a client with chronic venous insufficiency?
- B. Apply compression stockings.
- C. Encourage bed rest.
- D. Administer diuretics.
- E. Elevate the head of the bed.
Correct Answer: A
Rationale: Compression stockings improve venous return, reducing edema and stasis in chronic venous insufficiency. Bed rest is discouraged, diuretics are not primary, and head elevation is irrelevant.
A client with acromegaly will most likely experience which symptom?
- A. Bone pain
- B. Frequent infections
- C. Fatigue
- D. Weight loss
Correct Answer: A
Rationale: Acromegaly, caused by excess growth hormone, often leads to bone pain due to bone overgrowth. Infections , fatigue , and weight loss are less specific symptoms.
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse.
- A. What symptoms should the nurse expect in a client with type I diabetes and a blood sugar of 50 mg/dL?
- B. Confused with cold, clammy skin and a pulse of 110.
- C. Lethargic with hot, dry skin and rapid, deep respirations.
- D. Alert and cooperative with a BP of 130/80 and respirations of 1
- E. Short of breath, with distended neck veins and a bounding pulse of 96.
Correct Answer: A
Rationale: A blood sugar of 50 mg/dL indicates hypoglycemia, characterized by confusion, cold, clammy skin, and tachycardia (pulse 110) due to sympathetic activation. Hyperglycemia causes hot, dry skin and rapid respirations, while normal or fluid overload symptoms do not apply.
The nurse observes the certified nursing assistant doing all of the following. Which action needs correction?
- A. Changing the dressing of a client with an abdominal wound
- B. Asking a standing client to sit down while vital signs are taken
- C. Emptying a urine drainage bag from the tube at the bottom
- D. Changing water in the middle of a bed bath
Correct Answer: A
Rationale: Changing dressings requires nursing judgment and sterile technique, outside a CNA's scope. Other actions are within their role.
The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings should the nurse report immediately?
- A. Absence of bowel sounds.
- B. Mild abdominal distension.
- C. Pain at the incision site.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: Absence of bowel sounds on day 2 suggests ileus or obstruction, requiring immediate reporting. Options B, C, and D are expected or normal.