Nokea
Which of the following is not a risk factor for the development of atherosclerosis?
- A. A family history of early heart attack.
- B. Late onset of puberty.
- C. Total blood cholesterol level greater than 220 mg/dL.
- D. Elevated fasting blood glucose concentration.
Correct Answer: B
Rationale: Late onset of puberty is not a risk factor for atherosclerosis. Family history, high cholesterol, and elevated glucose are established risk factors.
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Vasopressin (Pitressin) is administered to the client with diabetes insipidus because it:
- A. Decreases blood pressure.
- B. Increases tubular reabsorption of water.
- C. Increases release of insulin from the pancreas.
- D. Decreases glucose production within the liver.
Correct Answer: B
Rationale: Vasopressin increases water reabsorption in the kidneys, reducing urine output in diabetes insipidus.
The nurse explains to the client that the main reason a back rub is used as therapy to relieve pain is because the massage:
- A. Blocks pain impulses from the spinal cord to the brain.
- B. Blocks pain impulses from the brain to the spinal cord.
- C. Stimulates the release of endorphins.
- D. Distracts the client's focus on the source of the pain.
Correct Answer: C
Rationale: Massage, like a back rub, stimulates endorphin release, which naturally reduces pain perception. It does not block pain impulses directly or act solely as a distraction.
The nurse is assessing a client with heart failure who is receiving home health care monitoring using electronic devices including scales, blood pressure monitoring, and structured questions to which the client responds daily on a touch-screen monitor. The nurse reviews data obtained within the last 3 days. The nurse calls the client to follow up. The nurse should ask the client which of the following first:
- A. How are you feeling today?'
- B. Are you having shortness of breath?'
- C. Did you calibrate the scales before using them?'
- D. How much fluid did you drink during the last 24 hours?'
Correct Answer: B
Rationale: A 5-lb weight gain in 3 days and rising blood pressure suggest fluid retention. Asking about shortness of breath first assesses for pulmonary edema, a serious complication.
Because a client has a Thomas splint, the nurse should assess the client regularly for which of the following?
- A. Signs of skin pressure in the groin area.
- B. Evidence of decreased breath sounds.
- C. Skin breakdown behind the heel.
- D. Urine retention.
Correct Answer: A
Rationale: The Thomas splint can cause pressure in the groin, requiring regular skin assessments to prevent breakdown.
A client who has undergone abdominal or pelvic surgery. In order to prevent deep vein thrombosis (DVT), the nurse should:
- A. Restrict fluids
- B. Encourage deep breathing
- C. Assist the client to remain sedentary
- D. Use pneumatic compression stockings
Correct Answer: D
Rationale: Pneumatic compression stockings prevent DVT post-surgery by promoting venous return and reducing stasis. Restricting fluids increases viscosity, deep breathing aids respiratory function, and remaining sedentary increases DVT risk.