Nokea
A client is admitted with renal calculi and is experiencing severe pain. Meperidine (Demerol) 75 mg IM is given prior to the change of shift.
Which of the following symptoms is MOST important for the nurse to report to the next shift?
- A. Nausea with a small amount of vomitus.
- B. Pain of five on a scale of one to ten.
- C. Change in the location and character of pain.
- D. No known drug allergies.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to renal calculi. (1) often accompanies pain, but is not most important to report to next shift (2) important, but not the highest priority (3) correct-location of the pain depends on location of renal stone; character of pain changes depending on location or movement of stone (4) important, but not the highest priority
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A client hospitalized with acute glomerulonephritis has a positive ASO titer. The nurse understands that the client's current illness is due to a:
- A. History of uncontrolled hypertension
- B. Prior bacterial infection
- C. Prolonged elevation in blood glucose
- D. Drug reaction that led to muscle breakdown
Correct Answer: B
Rationale: A positive antistreptolysin titer indicates infection with Group A β-hemolytic Streptococcus, a bacterial infection. Answers A, C, and D are not associated with acute glomerulonephritis so they are incorrect.
A client is admitted to the neurology unit for a myelogram.
It would be MOST important for the nurse to ask which of the following questions?
- A. Do you have any allergies?'
- B. Have you been drinking lots of fluids?'
- C. Are you wearing any metal objects?'
- D. Are you taking medication?'
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to a myelogram. (1) correct-dye is injected into subarachnoid space before an x-ray of spinal cord and vertebral column to assist in identifying spinal lesions; if client is allergic to dye, there is a major safety issue (2) important that client drink extra fluids after the Test to replace the CSF lost during Test (3) appropriate for magnetic resonance imaging (MRI) (4) obtain history of medication that can lower seizure threshold (phenothiazines, neuroleptics)
The nurse is caring for a client who had a stroke and is experiencing dysphagia. Which of the following nursing actions is the PRIORITY?
- A. Position the client upright during meals.
- B. Offer the client thin liquids to drink.
- C. Provide the client with a soft diet.
- D. Encourage the client to eat quickly.
Correct Answer: A
Rationale: Positioning the client upright during meals reduces the risk of aspiration, a life-threatening complication in dysphagia. Options B, C, and D are inappropriate: thin liquids increase aspiration risk, soft diets are secondary, and eating quickly exacerbates the problem.
A client is admitted for a series of Test s to verify the diagnosis of Cushing's syndrome.
Which of the following assessment findings, if observed by the nurse, would support this diagnosis?
- A. Buffalo hump, hyperglycemia, and hypernatremia.
- B. Nervousness, tachycardia, and intolerance to heat.
- C. Lethargy, weight gain, and intolerance to cold.
- D. Irritability, moon face, and dry skin.
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to Cushing's syndrome. (1) correct-Cushing's syndrome is characteristic of these assessments, as are weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (2) symptoms of hyperthyroidism (3) symptoms of hypothyroidism (myxedema) (4) symptoms of hypoparathyroidism
A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to
- A. promote verbal and nonverbal communication with both the client and the interpreter
- B. speak only a few sentences at a time and then pause for a few moments
- C. plan that the encounter will take more time than if the client spoke English
- D. ask the client to speak slowly and to look at the person spoken to
Correct Answer: A
Rationale: The nurse should communicate with the client and the family, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. Maintain eye contact with both the client and interpreter to elicit feedback and read nonverbal cues.