Nokea
During the physical assessment, the nurse determines the need to perform the bulge Test .
Which of the following statements, if made by the nurse, is BEST?
- A. Please lie down and extend your legs.
- B. Please bend over and touch your toes.
- C. Please hold both hands behind your back.
- D. Please bend your elbow.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-bulge Test confirms presence of fluid in the knee; client's leg should be extended and supported on the bed (2) observing curve of spine; scoliosis will cause lateral curve in the spine (3) unrelated to knee examination (4) Test s articulation of elbow
You may also like to solve these questions
The nurse on postpartum is preparing four clients for discharge. It would be MOST important for the nurse to refer which of the following clients for homecare?
- A. A 15-year-old who vaginally delivered a 7-lb male two days ago.
- B. An 18-year-old multipara who delivered a 9-lb female by cesarean section two days ago.
- C. A 20-year-old multipara who delivered 1 day ago and is complaining of cramping.
- D. A 22-year-old who delivered by cesarean section and is complaining of burning on urination.
Correct Answer: D
Rationale: Burning on urination suggests a urinary tract infection, requiring homecare follow-up. Options A, B, and C are routine postpartum findings.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about glipizide (Glucotrol). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication 30 minutes before breakfast.
- B. I should avoid drinking alcohol while taking this medication.
- C. I should report sweating or shakiness to my doctor.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping glipizide when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: pre-breakfast dosing maximizes efficacy, alcohol increases hypoglycemia risk, and sweating/shakiness indicate hypoglycemia.
The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-hysterectomy complication. Options A, C, and D are normal.
When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?
- A. Digestive problems
- B. Amenorrhea
- C. Electrolyte imbalance
- D. Blood disorders
Correct Answer: B
Rationale: Amenorrhea. Changes in reproductive hormones and in thyroid hormones can cause absence of menstruation, called amenorrhea, which contributes to osteoporosis and bone fractures.
A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer?
- A. Dairy products
- B. Carbonated beverages
- C. Refined sugars
- D. Luncheon meats
Correct Answer: D
Rationale: Luncheon meats , high in nitrates, are linked to gastric cancer risk. Dairy , carbonated beverages , and refined sugars are not strongly associated.