Nokea
Why must a nurse avoid disrupting bloodstains or tears on the clothing of a trauma client?
- A. The clothing is the property of another
- B. It facilitates repair and salvage of the clothing
- C. The clothing is potential evidence with legal implications
- D. It decreases trauma to family members
Correct Answer: C
Rationale: The correct answer is C because the clothing of a trauma client could potentially be considered evidence with legal implications. Preserving the bloodstains or tears on the clothing maintains the integrity of the evidence for forensic investigation or legal proceedings. Disrupting the bloodstains or tears could compromise the evidence and hinder any potential investigation or legal case. Choices A, B, and D are incorrect because the primary concern in this scenario is the legal implications and preservation of evidence, not ownership, repair, salvage, or minimizing trauma to family members.
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A nurse is assessing a patient who has a history of deep vein thrombosis (DVT). Which of the following findings would be most concerning?
- A. Pain and swelling in the leg.
- B. Redness and warmth around the affected area.
- C. Shortness of breath and chest pain.
- D. Pale skin and decreased pulse in the affected leg.
Correct Answer: C
Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function.
A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism.
B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism.
D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.
A woman is describing the problems she is having with her 2-year-old son. "He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens." The nurse's best verbal response would be:
- A. Go on, I'm listening.
- B. Fits? Tell me what you mean by this.
- C. Yes, it can be upsetting when a child has a fit.
- D. Don't be upset when he has a fit; every 2-year-old has fits.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates active listening and seeks clarification on the issue at hand. By asking the woman to explain what she means by "fits," the nurse can gain a better understanding of the child's behavior and provide appropriate support and guidance. This response shows empathy and a willingness to address the woman's concerns effectively.
Choice A is incorrect because it does not address the woman's specific concerns or invite further discussion. Choice C is incorrect because it simply acknowledges the woman's feelings without delving deeper into the issue. Choice D is incorrect as it dismisses the woman's feelings and generalizes the behavior as typical for all 2-year-olds without addressing her individual situation.
What term describes excessive stretching of a ligament, as seen in a client with a pulled ligament?
- A. sprain
- B. strain
- C. subluxation
- D. distortion
Correct Answer: B
Rationale: The correct answer is B: strain. A strain refers to excessive stretching or tearing of a muscle or tendon, not a ligament. A sprain (choice A) is the correct term for excessive stretching of a ligament. Subluxation (choice C) refers to partial dislocation of a joint, not a ligament injury. Distortion (choice D) is a general term that does not specifically describe ligament stretching. Therefore, the correct term for excessive stretching of a ligament is a sprain, making choice A the correct answer.
The major electrolytes in the extracellular fluid are:
- A. potassium and chloride
- B. potassium and phosphate
- C. sodium and chloride
- D. sodium and phosphate
Correct Answer: C
Rationale: The correct answer is C: sodium and chloride. In the extracellular fluid, sodium and chloride are the major electrolytes due to their roles in maintaining fluid balance, nerve function, and muscle contraction. Potassium and phosphate (choice B) are primarily found in intracellular fluid, while potassium and chloride (choice A) are not the major electrolytes in extracellular fluid. Similarly, sodium and phosphate (choice D) are not major extracellular electrolytes. Thus, choice C is the correct answer based on the significant presence and functions of sodium and chloride in the extracellular fluid.
What should be the first intervention for a client suspected of having a stroke?
- A. Monitor neurological status
- B. Perform a CT scan
- C. Administer fibrinolytics
- D. Perform MRI
Correct Answer: B
Rationale: The correct first intervention for a client suspected of having a stroke is to perform a CT scan (Choice B). This is because a CT scan can quickly identify the type of stroke (ischemic or hemorrhagic) and guide treatment decisions. Monitoring neurological status (Choice A) can be important but does not provide a definitive diagnosis. Administering fibrinolytics (Choice C) should only be done after confirming the type of stroke to avoid complications. Performing an MRI (Choice D) is more time-consuming and may not be feasible in the acute setting where quick intervention is crucial. Therefore, a CT scan is the most appropriate initial intervention for a suspected stroke.