Nokea
Which of the following statements best describes compartment syndrome?
- A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
- B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
- C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
- D. An injury causes pain and swelling of the median plantar nerve.
Correct Answer: B
Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.
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The nurse at a community health care clinic is teaching parents about measures to take to prevent and manage obesity in children. The nurse determines that the parents need additional teaching if they indicate that they will implement which measures? Select all that apply.
- A. Use foods as a reward.
- B. Offer options of healthy foods.
- C. Avoid eating at fast-food restaurants.
- D. Maintain healthy, personal eating habits.
- E. Allow eating in-between meals and snack times.
- F. Establish consistent times for meals and snacks.
Correct Answer: A,E
Rationale: Parents can implement several measures to prevent and manage obesity in their children. These measures include not using food as a reward; establishing consistent times for meals and snacks, and not allowing eating inbetween; offering only healthy food options; minimizing trips to fast-food restaurants; keeping unhealthy food out of the house; acting as a role model for children; encouraging the child to do fun, physical activities with the family; and praising the child for making appropriate food choices and increasing physical activity levels.
Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
- A. Kussmaul respirations
- B. Cheyne-Stokes respirations
- C. Biot's respirations
- D. Cluster breathing
Correct Answer: A
Rationale: Mr. N is most likely exhibiting Kussmaul respirations. Kussmaul respirations are a form of hyperventilation associated with conditions like metabolic acidosis. They are characterized by rapid, regular, and deep breathing. This type of respiratory pattern helps the body compensate for metabolic acidosis by attempting to blow off excess carbon dioxide. This pattern is different from Cheyne-Stokes respirations (choice B), which are characterized by alternating periods of deep, rapid breathing followed by apnea. Biot's respirations (choice C) are characterized by groups of quick, shallow inspirations followed by irregular periods of apnea, and Cluster breathing (choice D) involves clusters of breaths followed by periods of apnea, often seen in patients with brain injury or neurological conditions.
Which action by the client should lead the nurse to determine the need for further teaching regarding the use of the incentive spirometer?
- A. Inhales slowly
- B. Breathes through the nose
- C. Removes the mouthpiece to exhale
- D. Forms a tight seal around the mouthpiece with the lips
Correct Answer: B
Rationale: Incentive spirometry is ineffective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 5, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results.
The nurse provides home care instructions to a client diagnosed with cancer who has an implanted vascular access port. Which statement by the client indicates the need for further teaching?
- A. I should keep the site clean and dry.
- B. If the site becomes red, I will notify my doctor.
- C. I should pump the port daily to maintain patency.
- D. The port will need to be flushed with saline to maintain patency.
Correct Answer: C
Rationale: Implanted vascular access ports do not require daily pumping to maintain patency; this is incorrect. Keeping the site clean and dry, notifying the doctor about redness, and flushing with saline (or heparin, per agency protocol) are correct care measures.
A client has a prescription for ketoconazole. Which instruction should the nurse teach the client to follow while taking this medication?
- A. Avoid exposure to sunlight.
- B. Limit alcohol to 2 ounces per day.
- C. Take the medication with an antacid.
- D. Take the medication on an empty stomach.
Correct Answer: A
Rationale: The client should be taught that ketoconazole is an antifungal medication. The client should avoid exposure to sunlight because the medication increases photosensitivity. The client should avoid the concurrent use of alcohol because the medication is hepatotoxic. Antacids should be avoided for 2 hours after it is taken because gastric acid is needed to activate the medication. This medication should be taken with food or milk.