Nokea
Which tool or scale would you use for a focused neurological assessment of your client?
- A. The Lazarus Cognitive Appraisal Scale
- B. The Hamilton Rating Scale
- C. The McGill Scale
- D. The Rancho Los Amigos Scale
Correct Answer: D
Rationale: The Rancho Los Amigos Scale is used for assessing levels of consciousness and cognitive recovery in patients with brain injuries, ideal for a focused neurological assessment.
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A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should prioritize which of the following interventions?
- A. Administer regular insulin intravenously.
- B. Administer potassium supplements.
- C. Restrict fluid intake.
- D. Administer sodium bicarbonate.
Correct Answer: A
Rationale: Intravenous regular insulin is the priority to lower blood glucose and halt ketogenesis in diabetic ketoacidosis.
The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third maneuver is used to identify the presenting part. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the tips of the fi rst three fi ngers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fi ngers of both hands to palpate the uterine fundus. The second maneuver identifi es the back of the fetus, and the fourth maneuver identifies the cephalic prominence
The nurse is obtaining a health history for a client with osteoporosis. The nurse should specifically ask the client about which of the following? Select all that apply.
- A. Amount of alcohol consumed daily.
- B. Use of antacids.
- C. Dietary intake of fiber.
- D. Use of Vitamin K supplements.
- E. Intake of fruit juices.
Correct Answer: A, B
Rationale: Excessive alcohol consumption and frequent antacid use (which may contain aluminum, reducing calcium absorption) are risk factors for osteoporosis. Fiber, vitamin K, and fruit juices are less relevant.
The nurse is visiting a client who has been prescribed topical clotrimazole. The nurse should educate the client to the fact that this medication will alleviate which condition?
- A. Pain
- B. Rash
- C. Fever
- D. Sneezing
Correct Answer: B
Rationale: Clotrimazole is a topical antifungal used in the treatment of cutaneous fungal infections and will alleviate an associated rash. The nurse teaches the client that it is used for this purpose. It is not used for pain, sneezing, or fever.
How many units of heparin would you administer subcutaneously using the below information? Doctor's order: 6,500 units of heparin subcutaneously Medication label: 4,500 units in one mL
- A. 1.4 mL
- B. 1.5 mL
- C. 1.475 mL
- D. 1.425 mL
- E. 1.375 mL
Correct Answer: A
Rationale: To calculate: 6,500 units ÷ 4,500 units/mL = 1.444 mL, rounded to 1.4 mL for practical administration.