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1. What are the risk factors for deep vein thrombosis (DVT) and how can it be prevented?
- A. Immobility and oral contraceptive use
- B. Pregnancy and smoking
- C. Obesity and varicose veins
- D. Hypertension and high cholesterol
Correct answer: A
Rationale: The correct answer is A: Immobility and oral contraceptive use. Immobility and oral contraceptive use are significant risk factors for deep vein thrombosis (DVT). Immobility leads to blood stasis, increasing the risk of clot formation, while oral contraceptive use can promote hypercoagulability. Prevention strategies for DVT include promoting mobility to enhance blood circulation and using anticoagulants to prevent clot formation. Choices B, C, and D are incorrect. While pregnancy and smoking can increase the risk of DVT, they are not the specific factors mentioned in the question. Similarly, obesity and varicose veins, as well as hypertension and high cholesterol, are not the primary risk factors associated with DVT.
2. What are the signs and symptoms of a potential infection?
- A. Fever, chills, and increased heart rate
- B. Increased white blood cell count and fever
- C. Shortness of breath and confusion
- D. Sweating and low blood pressure
Correct answer: A
Rationale: The correct answer is A: Fever, chills, and increased heart rate are classic signs of an infection. These symptoms indicate the body's response to an invading pathogen. Choice B, 'Increased white blood cell count and fever,' is not a primary symptom that a person would typically notice themselves, and white blood cell count needs to be tested. Choice C, 'Shortness of breath and confusion,' may indicate other conditions like heart or lung issues rather than a general infection. Choice D, 'Sweating and low blood pressure,' are not specific to infections and can be caused by various factors like heat or dehydration.
3. What is the first step in managing a client with delirium?
- A. Administer sedative medication to calm the client
- B. Identify any reversible causes of delirium
- C. Limit environmental stimulation to reduce anxiety
- D. Administer antipsychotic medication to control behavior
Correct answer: B
Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.
4. A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following findings should the nurse identify as an indication of impending death?
- A. Hypertension.
- B. Tachycardia.
- C. Cold extremities.
- D. Diaphoresis.
Correct answer: C
Rationale: Cold extremities are a critical sign of impending death as they indicate decreased circulation, leading to poor perfusion to the extremities. This phenomenon occurs as the body redirects blood flow to vital organs, preparing for the end of life. Hypertension and tachycardia are less likely to be seen in the terminal phase and are usually associated with other conditions like shock or sepsis. Diaphoresis, or excessive sweating, may occur in various situations but is not a specific indicator of impending death in this context.
5. A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?
- A. Use a separate washcloth for the child
- B. Apply cold compresses to the eyes
- C. Apply warm compresses to the eyes
- D. Keep the child home until symptoms have resolved
Correct answer: A
Rationale: The correct answer is to use a separate washcloth for the child. This is important to prevent the spread of infection when a child has conjunctivitis. Using the same washcloth can lead to cross-contamination and further spread of the condition. Applying cold or warm compresses may provide comfort but do not address the prevention of spreading the infection. Keeping the child home until symptoms have resolved may be necessary, but the primary focus should be on preventing the spread of the infection within the household.
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