Nokea
A client with severe bilateral peripheral edema.
Which of the following is the BEST way for the nurse to determine the degree of edema in a limb, and the client's response to treatment?
- A. Measure both limbs with the tape measure and compare.
- B. Depress the skin and rank the degree of pitting.
- C. Describe the swelling in the affected area.
- D. Pinch the skin and note how quickly it returns to normal.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not the best way to evaluate for peripheral edema (2) correct-severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting) (3) not as objective (4) is used for evaluating hydration
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The nurse is teaching a young woman how to perform breast self-examination. Which comment, if made by the client, indicates that the teaching has been effective?
- A. I should examine my breasts every year.'
- B. I need to see the doctor every six months for a breast exam.'
- C. I don't need to worry about breast cancer for a few years.'
- D. I should examine all parts of my breasts while both lying down and standing up.'
Correct Answer: D
Rationale: Effective breast self-examination involves checking all breast areas in both lying and standing positions monthly. Yearly exams, frequent doctor visits, or delaying concern are incorrect.
An adult who has just been diagnosed with pulmonary tuberculosis asks the nurse how long he will have to be in isolation. What should be included in the nurse's reply?
- A. Isolation is for the duration of the treatment, which is at least 26 weeks.
- B. Isolation is necessary as long as the client has a cough.
- C. When the client has three negative sputum specimens, isolation is discontinued.
- D. When the evening fevers and night sweats subside, isolation is discontinued.
Correct Answer: C
Rationale: Isolation for pulmonary TB ends when three consecutive sputum samples are negative, indicating non-infectiousness, typically before the full 6-month treatment.
A patient with second- and third-degree burns. The client is receiving morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention.
Which of the following actions, if taken by the nurse, is BEST?
- A. Recommend that the morphine dose be decreased.
- B. Withhold the pain medication.
- C. Administer the medication by another route.
- D. Explore alternative pain management techniques.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) could indicate a possible impending ileus, this option is not ideal (2) inappropriate (3) inappropriate (4) correct-morphine is drug of choice for burn pain management; when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
- A. Impaired gas exchange related to acute infection and sputum production
- B. Ineffective airway clearance related to sputum production and ineffective cough
- C. Ineffective breathing pattern related to acute infection
- D. Anxiety related to hospitalization and role conflict
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.
The client says to the nurse, 'I don't see why I should live any longer.' How should the nurse respond initially?
- A. Ask the client why she doesn't want to live any longer
- B. Ask the client if she is considering suicide
- C. Tell the client that life is precious and worth living
- D. Help the client see the good things that she has in her life
Correct Answer: B
Rationale: Expressing a desire to not live suggests suicidal ideation; directly asking about suicide assesses risk and guides intervention. Exploring reasons, affirming life, or highlighting positives are secondary.