Nokea
Your client has presented in the emergency department with a sudden onset of shortness of breath, dysphagia, dyspnea, coughing, and pain in the chest, arms, neck, and back. Which of the following would you most likely suspect?
- A. Hypovolemic shock
- B. Septic shock
- C. A dissected thoracic aortic aneurysm
Correct Answer: C
Rationale: Sudden onset of these symptoms, especially chest and back pain, suggests a dissected thoracic aortic aneurysm, a life-threatening condition requiring urgent intervention.
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During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the clientiant tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. Which of the following would be the nurse's best response?
- A. It is permissible to give the baby cereal if it is thinned with formula.'
- B. The time for starting cereal varies, so check with your pediatrician.'
- C. Formula is the food best digested by the baby until about 4 to 6 months of age.'
- D. If cereal is given too early in life, the undigested food can lead to a need for surgery.'
Correct Answer: C
Rationale: Formula is best for infants until 4-6 months, as early introduction of solids like cereal can cause digestive issues.
A client who voluntarily admitted herself to the mental health hospital adamantly demands to be discharged immediately. What is the most appropriate response by the nurse?
- A. We hate to see you go, but that is your right. I'll get the forms for you so you can go.'
- B. I'm sorry, but your lawyer or family must request such forms when you are hospitalized.'
- C. I will get the forms, but your psychiatrist will need to see you before you leave.'
- D. Are you sure we can't convince you to stay here in a few days? You'll return to a full valid and there are several issues we need to address.'
Correct Answer: C
Rationale: For voluntary admissions, clients can request discharge, but a psychiatric evaluation is typically required to ensure safety. This response ensures protocol is followed while addressing the client's request.
A 38-year-old client with a history of type 1 diabetes mellitus is admitted with an infected foot ulcer. The nurse should recognize that wound healing may be delayed because of:
- A. Increased tissue perfusion.
- B. Impaired collagen synthesis.
- C. Enhanced immune response.
- D. Increased fibroblast activity.
Correct Answer: B
Rationale: In diabetes, impaired collagen synthesis due to poor glycemic control delays wound healing, increasing infection risk.
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
- A. Cleanse the meatus with an alcohol swab
- B. Use clean gloves during insertion
- C. Apply sterile lubricant to the catheter tip
- D. Insert the catheter without a drape
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.
A 10-year-old child has the following blood glucose readings during a 24-hour period. Which reading requires the most immediate intervention?
- A. 50 mg/dL.
- B. 100 mg/dL.
- C. 150 mg/dL.
- D. 200 mg/dL.
Correct Answer: A
Rationale: A blood glucose of 50 mg/dL indicates hypoglycemia, requiring immediate intervention to prevent neurological complications.