Nokea
While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?
- A. A 79-year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. A client who had 3 episodes of incontinent diarrhea
- D. An 80-year-old ambulatory diabetic client
Correct Answer: A
Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to being malnourished and on bed rest, leading to decreased mobility and poor nutrition. This combination puts the client at significant risk for skin breakdown and pressure ulcers. Choice B is incorrect because although obesity is a risk factor for developing pressure ulcers, immobility and poor nutrition are higher risk factors. Choice C is incorrect as incontinence can contribute to skin breakdown but is not as high a risk factor as immobility and poor nutrition. Choice D is incorrect as an ambulatory client, even if diabetic, has better mobility than a bedridden client and is at lower risk for developing decubitus ulcers.
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A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?
- A. Pap smear is sufficient to detect ovarian cancer
- B. Surgery is unnecessary based on negative Pap smear
- C. Further evaluation involving surgery may be needed
- D. No further tests are needed
Correct Answer: C
Rationale: A negative Pap smear does not rule out ovarian cancer, which often requires more comprehensive evaluation, including imaging studies or surgery. The client should be informed that the Pap smear primarily detects cervical cancer, not ovarian cancer. Therefore, further evaluation involving imaging studies or surgery may be necessary to determine the presence of ovarian cancer. Choice A is incorrect because a Pap smear is not sufficient to detect ovarian cancer. Choice B is incorrect because surgery may be necessary for further evaluation if ovarian cancer is suspected. Choice D is incorrect because further tests are needed to confirm or rule out ovarian cancer.
The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?
- A. Question the client about the frequency of falls.
- B. Request the client to lie still during the assessment.
- C. Ask how often episodes of sundowning are experienced.
- D. Assist the client with values clarification about end-of-life care.
Correct Answer: A
Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.
The healthcare provider is assessing a client who has just received anesthesia. What is the most critical finding to report to the healthcare provider?
- A. Client reports dizziness
- B. Client has a drop in blood pressure
- C. Client experiences mild nausea
- D. Client reports dry mouth
Correct Answer: B
Rationale: A significant drop in blood pressure following anesthesia could indicate a serious reaction, such as hypovolemia or anesthetic-induced hypotension. This requires immediate medical attention, while other symptoms like dizziness, mild nausea, and dry mouth are more common and less critical. Dizziness could be expected due to the effects of anesthesia, mild nausea is a common side effect, and dry mouth is a known effect of anesthesia as well.
The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading?
- A. Frequent syncope
- B. Muscle rigidity
- C. Gait instability
- D. Fine motor tremors
Correct Answer: A
Rationale: The correct answer is A: 'Frequent syncope.' Orthostatic hypotension, common in Parkinson's disease, often causes syncope (fainting) when blood pressure drops upon standing. This information is critical for planning safe blood pressure measurements, ensuring readings are taken in both lying and standing positions to assess for sudden drops in pressure. Muscle rigidity, tremors, or gait instability are important symptoms in Parkinson's disease but are not directly related to blood pressure assessment.
A client with a ruptured spleen underwent an emergency splenectomy. Twelve hours later, the client's urine output is 25 ml/hour. What is the most likely cause?
- A. This is a normal finding after surgery.
- B. Oliguria signals tubular necrosis related to hypoperfusion.
- C. Oliguria signals dehydration and fluid loss.
- D. Urine output of 25 ml/hour is an expected finding after splenectomy.
Correct Answer: B
Rationale: Oliguria, or decreased urine output, after surgery can indicate tubular necrosis due to hypoperfusion, which may require intervention to restore renal function. Choice A is incorrect as oliguria is not a normal finding after surgery. Choice C is incorrect because dehydration is less likely in this context compared to tubular necrosis. Choice D is incorrect as a urine output of 25 ml/hour is not expected after splenectomy and should raise concern for renal impairment.