Nokea
Which of the following statements are correct regarding glomus tumours?
- A. These tumours rarely affect the nail beds
- B. They are extremely painful
- C. They are usually malignant
- D. A glomus body is found in the epidermis
Correct Answer: B
Rationale: Glomus tumors are extremely painful and arise from the glomus body located in the dermis.
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The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?
- A. Muffled heart sounds
- B. A rise in blood pressure
- C. Jugular venous distention
- D. Client expressions of dyspnea
Correct Answer: B
Rationale: Relieving tamponade improves cardiac output, raising BP.
The nurse is caring for a client six (6) hours postoperative right total knee replacement. Which data should the nurse report to the surgeon?
- A. A total of 100 mL of red drainage in the autotransfusion drainage system.
- B. Pain relief after using the patient-controlled analgesia (PCA) pump.
- C. Cool toes, distal pulses palpable, and pale nailbeds bilaterally.
- D. Urinary output of 60 mL of clear yellow urine in three (3) hours.
Correct Answer: C
Rationale: Cool toes and pale nailbeds suggest possible circulatory compromise, warranting immediate reporting.
The client is postoperative retinal detachment surgery, and gas tamponade was used to flatten the retina. Which intervention should the nurse implement first?
- A. Teach the signs of increased intraocular pressure.
- B. Position the client as prescribed by the surgeon.
- C. Assess the eye for signs/symptoms of complications.
- D. Explain the importance of follow-up visits.
Correct Answer: B
Rationale: Positioning as prescribed (often face-down or specific angles) is critical first to maintain the gas bubble's pressure on the retina, ensuring surgical success.
The nurse is assessing the client's sensory system. Which assessment data indicate an abnormal stereognosis test?
- A. The client is unable to identify which way the toe is being moved.
- B. The client cannot discriminate between sharp and dull objects.
- C. The toes contract and draw together when the sole of the foot is stroked.
- D. The client is unable to identify a key in the hand with both eyes closed.
Correct Answer: D
Rationale: Stereognosis tests tactile recognition; inability to identify objects indicates sensory dysfunction.
A nurse is preparing to perform the physical assessment of a newly admitted patient. During which of the following components of the assessment should the nurse wear gloves?
- A. Palpation of the patients scalp
- B. Palpation of a rash on the patients trunk
- C. Palpation of the patients fingers
- D. Palpation of intact skin on the back
Correct Answer: B
Rationale: Gloves are worn during skin examination if a rash or lesions are to be palpated. It is not normally necessary to wear gloves to palpate intact skin unless contact with body fluids is foreseeable.