Nokea
A client has a blood pressure of 142/92 mmHg. Which classification is appropriate for the nurse to use when documenting this data?
- A. Normal
- B. Hypertension stage I
- C. Prehypertension
- D. Hypertension stage II
Correct Answer: D
Rationale: A blood pressure reading of 142/92 mmHg falls into the category of Hypertension Stage II based on the guidelines from the American Heart Association. In this classification, systolic blood pressure is 140-159 mmHg and diastolic blood pressure is 90-99 mmHg. Stage II hypertension indicates that the individual has a significantly elevated blood pressure level that requires prompt management and monitoring. It is crucial for the nurse to document this accurately to ensure appropriate interventions are provided to the client.
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During what period of gestation do congenital heart defects usually develop?
- A. First 8 weeks of gestation
- B. Second trimester
- C. Third trimester
- D. Last 4 weeks of gestation
Correct Answer: A
Rationale: Congenital heart defects typically develop during the first 8 weeks of gestation when the baby's heart is forming. This is a critical period of organogenesis, where the heart undergoes complex development and any disruptions during this time can lead to structural abnormalities in the heart. Factors such as genetics, environmental influences, and certain maternal health conditions can contribute to the development of congenital heart defects during this early stage of pregnancy. It is crucial for mothers to receive proper prenatal care to help reduce the risk of congenital heart defects and other birth abnormalities.
The nurse is teaching a group of community members about measures to reduce the risk of bladder cancer. What should the nurse include when providing these instructions? Select all that apply.
- A. Empty the bladder every 2 hours
- B. Do not start smoking; if you smoke, stop
- C. Increase the intake of fluids and vegetables
- D. Avoid using hair dyes and pesticides in the home e. Limit the intake of coffee and other caffeinated beverages
Correct Answer: A
Rationale: A. Empty the bladder every 2 hours: Regularly emptying the bladder helps reduce the exposure of the bladder to potentially harmful substances that can increase the risk of developing bladder cancer.
During an assessment, the nurse determines that a patient with knee pain is at risk for osteoarthritis. What did the nurse assess in this patient?
- A. Having a history of falls
- B. Eating a diet high in calcium
- C. Walking 30 minutes each day
- D. Being overweight by 30 pounds
Correct Answer: D
Rationale: Osteoarthritis is a condition where the protective cartilage that cushions the ends of bones wears down over time. Excess weight puts extra stress on the joints, particularly weight-bearing joints like the knees. Being overweight by 30 pounds increases the risk of developing osteoarthritis in the knees because the added weight can accelerate the breakdown of cartilage. Therefore, the nurse identified the patient as at risk for osteoarthritis due to being overweight by 30 pounds.
During the physical examination of a client who took a fall that fractured his hip, the nurse notices an impairment of the client's hearing, but that the client's visual acuity and motor function do not seem to be impaired. The client answers questions very precisely and readily grasps the meaning of everything the nurse says when the client can face the nurse. When teaching this client, the nurse should make it a priority to
- A. make verbal instructions face to face with the client.
- B. provide only written instructions.
- C. use only visual media.
- D. use only physical demonstrations with written instructions.
Correct Answer: A
Rationale: The client in this scenario has an impairment of hearing, so it is essential to ensure effective communication by facing the client when providing verbal instructions. By facing the client, the nurse can help the client by making it easier to lip-read and pick up verbal cues, improving the client's ability to understand the instructions clearly. This approach demonstrates sensitivity to the client's needs and promotes better communication during teaching sessions. Providing written instructions alone (option B), using only visual media (option C), or relying solely on physical demonstrations with written instructions (option D) may not be as effective for this particular client with impaired hearing.
A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. Which should the nurse include when teaching the client about intermittent claudication?
- A. It causes pain that occurs during periods of inactivity.
- B. It causes pain that increases when the legs are elevated and decreases when the legs are dependent.
- C. It causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity.
- D. It is often described as a burning sensation in the lower legs.
Correct Answer: C
Rationale: Intermittent claudication is a symptom of peripheral vascular disease (PVD) characterized by cramping or aching pain in the lower extremities and buttocks that occurs with a predictable level of activity, such as walking a certain distance. This pain typically resolves with rest. The pain is due to inadequate blood flow to the muscles during activity, causing a buildup of lactic acid, which leads to muscle pain. This symptom is an important indicator of decreased arterial blood flow and is a common presentation in individuals with PVD. Therefore, when teaching the client about intermittent claudication, the nurse should emphasize the predictable nature of the pain related to activity and the relief experienced with rest.