Question

ence level eso ns do nt cause mental deterioration A common characteristics of idiopathic epilepsy is committing acts of violence Idiopathic epilepsy is a form of mental illness D. A client has been hospitalized after an automobile accident. A full leg cast applied while inside the 33 emergency room. The most important reason for the nurse to elevate the casted leg is to: A. Reduce the drying time B. Decrease irritation to the skin Improve venous return D Promote the client's comfort C 34. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client? Clean the meatus, begin vomiting, and then catch the urine stream B. Void a little, clean the meatus, then collect specimen C. Clean the meatus, then urinate into container D. Void continuously and catch some of the urine. A 35 The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing the client? ing edema of feet Apical pulse rate of 110 ckles that clear with cough The client sleepine with no pillow and eupnea Radial pulse rate of 90 and capillary refiN time less than 3 seconds D 36. The nurse is assessing the client with canse rt failure. Which signs and symptoms would indicate that the medical treatment ha na has globe from 3+ to 4+ The client is able te take the radial pulse accurateyithout dyspnea has minimal salar Mein distention e e developing a nursing care plan for a client diagnased with e 37 The nurse nursing agnesis o written ars os e client? The client will: arge e, and s? with no s3 heard be end of shift e an Turn, cough, and deep breather every two (2) hours pulse oximeter reading of 98% by say tw C of care. D Have e client diagnosed with congestive heart developing a discharge- 38. The nurse failure. Which intervention should be included in the plan? Select all that apply.

Answer 1

Answers:

33. C. Improve venous return.

Rationale:

Elevating the leg cast with extra pillows will improve the venous return and thereby reduce the risk of swelling. Venous return prevents the formation of thrombosis in the lower leg.

34. A. Clean the meatus, begin voiding and then catch the midstream.

Rationale:

Collecting a clear sample is necessary to avoid contamination of the specimen. First, should clean the urinary meatus with wet wipes. Then void a little and then stop. then place the sterile container and then fill half of the cup with urine. Closed the container tightly and then wash your hands.

35. A. Apical pulse of 110 and 4+pitting edema of feet.

Rationale:

In congestive heart failure, the patient has a rapid pulse rate and swelling of hands and legs. This occurs due to the presence of fluid in the lungs. The patient usually suffered from persistent cough with white or pink color phlegm which is not expelled by cough. So B is not an appropriate one. CHF patients usually suffer from shortness of breath and able to sleep with two or three pillows. So option C also incorrect. Radial pulse cannot be able to check appropriately. So option D also incorrect.

36. C. The client is able to perform the activities of daily living without dyspnea.

Rationale:

The effectiveness of treatment can be evaluated by assessment of the patient to do their self-care activities. Self-management of the patient is necessary before getting a discharge.

37. C. Have an audible S1 and S2 sound with no S3 heard at the end of shift.

Rationale:

S3 sound indicates the failure of the left ventricle to pump out the blood. So the heart sounds should be monitored appropriately.