NUR 131 EXAM 1 EAQ QUESTIONS WITH 100%
CORRECT ANSWERS!!
Which diagnostic exam would be used to detect muscle weakness?
- Arthroscopy
- Radiography
- Myelography
- Electromyography Answer - - Electromyography
Rationale: Electromyography is performed to detect diffused or localized
muscle weakness by determining the electric potential generated in an
individual.
When obtaining a health history from the newly admitted client who has
chronic pain in the right knee, which pain assessment data would the nurse
include? Select all that apply.
- Pain history, including location, intensity, and quality of pain.
- Client's purposeful body movement in arranging the papers on the bedside
table.
- Pain pattern, including precipitating and alleviating factors.
- Vital signs, such as increased blood pressure and heart rate.
- The client's family statement about increases in pain with ambulation. Answer
- - Pain history, including location, intensity, and quality of pain.
- Pain pattern, including precipitating and alleviating factors.
,Rationale:
The initial pain assessment should include information about the location,
quality, intensity, onset, duration, and frequency of pain, as well as factors that
relieve or exacerbate the pain.
Which nursing intervention would the nurse include in the plan of care for a
client after a hip replacement. Select all that apply.
- Place a pillow between the client's legs.
- Require the client to sit in an armless chair.
- Cross the client's legs at the ankles and knees.
- Require the client to use an elevated toilet seat.
- Keep the client's hip in a neutral, straight position. Answer - - Place a pillow
between the client's legs.
- Require the client to use an elevated toilet seat.
- Keep the client's hip in a neutral, straight position.
Rationale:
Using a pillow between the legs provides comfort and helps keep the joint
abducted. Use of an elevated toilet seat allows for easy movement and
prevents hip dislodgement. Keeping the client's hip in a neutral, straight
position prevents pain and discomfort and hip dislocation.
Five days after a client has abdominal surgery the nurse assess the client's
incision site for signs of dehiscence. Which clinical finding supports that the
client is experiencing wound dehiscence?
- Increased bowel sounds.
, - Loosening of intact sutures.
- Sudden increase in serosanguineous drainage.
- Purplish color of the incision. Answer - - Sudden increase in serosanguineous
drainage.
Rationale:
Serosanguineous drainage that suddenly increases from the wound or on the
dressing forewarns about separation of the wound edges (dehiscence);
dehiscence may progress to movement of abdominal organs outside of the
abdominal cavity (evisceration).
Which type of immunity will clients acquire through immunizations with live or
killed vaccines?
- Natural active immunity.
- Artificial active immunity.
- Natural passive immunity.
- Artificial passive immunity. Answer - - Artificial active immunity.
Rationale:
Artificial active immunity is acquired through immunization with live or killed
vaccines.
Which action would the nurse implement when a client develops an
anaphylactic reaction? Select all that apply.
- Initially, apply oxygen at 90% to 100% per nasal cannula.
- Call the Rapid Response Team and have the crash cart retrieved.
CORRECT ANSWERS!!
Which diagnostic exam would be used to detect muscle weakness?
- Arthroscopy
- Radiography
- Myelography
- Electromyography Answer - - Electromyography
Rationale: Electromyography is performed to detect diffused or localized
muscle weakness by determining the electric potential generated in an
individual.
When obtaining a health history from the newly admitted client who has
chronic pain in the right knee, which pain assessment data would the nurse
include? Select all that apply.
- Pain history, including location, intensity, and quality of pain.
- Client's purposeful body movement in arranging the papers on the bedside
table.
- Pain pattern, including precipitating and alleviating factors.
- Vital signs, such as increased blood pressure and heart rate.
- The client's family statement about increases in pain with ambulation. Answer
- - Pain history, including location, intensity, and quality of pain.
- Pain pattern, including precipitating and alleviating factors.
,Rationale:
The initial pain assessment should include information about the location,
quality, intensity, onset, duration, and frequency of pain, as well as factors that
relieve or exacerbate the pain.
Which nursing intervention would the nurse include in the plan of care for a
client after a hip replacement. Select all that apply.
- Place a pillow between the client's legs.
- Require the client to sit in an armless chair.
- Cross the client's legs at the ankles and knees.
- Require the client to use an elevated toilet seat.
- Keep the client's hip in a neutral, straight position. Answer - - Place a pillow
between the client's legs.
- Require the client to use an elevated toilet seat.
- Keep the client's hip in a neutral, straight position.
Rationale:
Using a pillow between the legs provides comfort and helps keep the joint
abducted. Use of an elevated toilet seat allows for easy movement and
prevents hip dislodgement. Keeping the client's hip in a neutral, straight
position prevents pain and discomfort and hip dislocation.
Five days after a client has abdominal surgery the nurse assess the client's
incision site for signs of dehiscence. Which clinical finding supports that the
client is experiencing wound dehiscence?
- Increased bowel sounds.
, - Loosening of intact sutures.
- Sudden increase in serosanguineous drainage.
- Purplish color of the incision. Answer - - Sudden increase in serosanguineous
drainage.
Rationale:
Serosanguineous drainage that suddenly increases from the wound or on the
dressing forewarns about separation of the wound edges (dehiscence);
dehiscence may progress to movement of abdominal organs outside of the
abdominal cavity (evisceration).
Which type of immunity will clients acquire through immunizations with live or
killed vaccines?
- Natural active immunity.
- Artificial active immunity.
- Natural passive immunity.
- Artificial passive immunity. Answer - - Artificial active immunity.
Rationale:
Artificial active immunity is acquired through immunization with live or killed
vaccines.
Which action would the nurse implement when a client develops an
anaphylactic reaction? Select all that apply.
- Initially, apply oxygen at 90% to 100% per nasal cannula.
- Call the Rapid Response Team and have the crash cart retrieved.
