Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg pharm comprehensive proctored exam. Take the full exam now
Full Explanation
The client is at risk for developing pressure injury and foot drop. Given the client's history of a recent cerebrovascular accident (CVA) and the inability to reposition themselves, there is a heightened risk for pressure injuries due to prolonged periods of immobility. Additionally, the observed occasional movement of the left arm and leg with the right side without movement suggests a potential for muscle weakness or paralysis, which can lead to foot drop, characterized by difficulty in lifting the front part of the foot.
Similar Questions
A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?
A. Pernicious anemia
Pernicious anemia is a condition related to vitamin B12 deficiency and does not typically cause blood-tinged urine.
B. Prostate enlargement
Prostate enlargement (benign prostatic hyperplasia) can cause urinary symptoms like hesitancy and frequency but does not directly cause blood-tinged urine.
C. Dehydration
Dehydration can lead to concentrated urine and urinary tract irritation but does not typically cause blood-tinged urine.
D. Bladder infection
Blood-tinged urine in a client with an indwelling urinary catheter is concerning for a bladder infection, especially if accompanied by other signs like fever or foul odor.
Full Explanation
A. Pernicious anemia is a condition related to vitamin B12 deficiency and does not typically cause blood-tinged urine.
B. Prostate enlargement (benign prostatic hyperplasia) can cause urinary symptoms like hesitancy and frequency but does not directly cause blood-tinged urine.
C. Dehydration can lead to concentrated urine and urinary tract irritation but does not typically cause blood-tinged urine.
D. Blood-tinged urine in a client with an indwelling urinary catheter is concerning for a bladder infection, especially if accompanied by other signs like fever or foul odor.
A nurse is teaching an adult client who has a low literacy level about self administration of a subcutaneous medication. Which of the following strategies should the nurse use to promote the client's understanding?
A. Provide the client with written materials using large print.
Providing written materials with large print helps accommodate low literacy levels by enhancing readability and comprehension, but assessing the client’s ability to demonstrate the skill is more crucial to assess understanding.
B. Provide a long teaching session.
Long teaching sessions can overwhelm clients with low literacy levels and may not improve understanding.
C. Simplify terms using acronyms.
Using acronyms may confuse clients with low literacy levels if they are not familiar with medical abbreviations.
D. Ask the client to demonstrate the skill.
Asking the client to demonstrate the skill is important, since it allows the nurse to assess the client's comprehension and correct any mistakes during the learning process.
Full Explanation
A. Providing written materials with large print helps accommodate low literacy levels by enhancing readability and comprehension, but assessing the client’s ability to demonstrate the skill is more crucial to assess understanding.
B. Long teaching sessions can overwhelm clients with low literacy levels and may not improve understanding.
C. Using acronyms may confuse clients with low literacy levels if they are not familiar with medical abbreviations.
D. Asking the client to demonstrate the skill is important, since it allows the nurse to assess the client's comprehension and correct any mistakes during the learning process.
A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspect which of the following types of anemia?
A. Sickle cell anemia
Sickle cell anemia typically presents with hemolytic crises and sickle-shaped red blood cells, not necessarily heavy menstrual bleeding.
B. Folic acid deficiency anemia
Folic acid deficiency anemia can cause macrocytic anemia but is less likely to cause heavy menstrual bleeding as the primary symptom.
C. Pernicious anemia
Pernicious anemia is due to vitamin B12 deficiency and typically presents with neurological symptoms along with anemia, not necessarily heavy menstrual bleeding.
D. Iron-deficiency anemia
Iron-deficiency anemia commonly presents with weakness, fatigue, and heavy menstrual bleeding due to inadequate iron for red blood cell production.
Full Explanation
A. Sickle cell anemia typically presents with hemolytic crises and sickle-shaped red blood cells, not necessarily heavy menstrual bleeding.
B. Folic acid deficiency anemia can cause macrocytic anemia but is less likely to cause heavy menstrual bleeding as the primary symptom.
C. Pernicious anemia is due to vitamin B12 deficiency and typically presents with neurological symptoms along with anemia, not necessarily heavy menstrual bleeding.
D. Iron-deficiency anemia commonly presents with weakness, fatigue, and heavy menstrual bleeding due to inadequate iron for red blood cell production.