Nokea
A child with a diagnosis of umbilical hernia has been scheduled for surgical repair in 2 weeks. The clinic nurse instructs the parents about the signs of possible hernia strangulation. The nurse tells the parents that which sign requires primary health care provider notification?
- A. Fever
- B. Diarrhea
- C. Vomiting
- D. Constipation
Correct Answer: C
Rationale: The parents of a child with an umbilical hernia need to be instructed regarding the signs/symptoms of strangulation, which include vomiting, pain, and an irreducible mass at the umbilicus. Fever, diarrhea, and constipation are not signs of hernia strangulation. The parents should be instructed to contact the primary health care provider immediately if strangulation is suspected.
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The nurse creates a plan of care for an older client diagnosed with diabetes mellitus. It is important that the nurse plans to complete which action first?
- A. Structure menus for adherence to diet.
- B. Teach with videotapes showing insulin administration to ensure competence.
- C. Encourage dependence on others to prepare the client for the chronicity of the disease.
- D. Assess the client's ability to read label markings on syringes and blood glucose monitoring equipment.
Correct Answer: D
Rationale: Assessing the client's ability to read syringe and glucose monitor markings is the first step, ensuring they can manage self-care. Structuring menus or teaching with videos assumes capability, and encouraging dependence is inappropriate.
The nurse is performing an assessment on an older client. Which signs/symptoms are age-related changes in the eye? Select all that apply.
- A. Clear sclera
- B. Blurred vision
- C. Protruding cornea
- D. Increased tear production
- E. Diminished pupillary adaptation to darkness
- F. Increased ability to discriminate among colors
Correct Answer: B,E
Rationale: Age-related changes in the eye include flattening of the cornea, which causes blurred vision; poor pupillary adaptation to darkness; yellowing sclera; a sunken appearance; diminished tear production; diminished ability to discriminate among colors; and reduced ocular muscle strength.
A nurse is preparing to talk about hormone replacement therapy (HRT) to a group of women at a women's fair at the local hospital. Which statements regarding HRT are correct? Select all that apply.
- A. HRT decreases the risk of breast cancer.
- B. HRT decreases the risk of stroke in postmenopausal women.
- C. HRT lowers the risk of bone fractures caused by osteoporosis.
- D. HRT increases the risk of bone fractures caused by osteoporosis.
- E. HRT decreases the risk of coronary artery disease (CAD) in women who do not smoke.
Correct Answer: C
Rationale: HRT reduces fracture risk by improving bone density. It increases breast cancer, stroke, and CAD risks, and does not decrease CAD risk in non-smokers.
The clinic nurse is talking to a client who has just been prescribed hormone replacement therapy (HRT). Which statement about HRT by the nurse is correct?
- A. HRT decreases the risk of stroke.
- B. HRT increases the risk of osteoporosis.
- C. HRT decreases the risk of deep vein thrombosis.
- D. HRT increases the risk of coronary artery disease.
Correct Answer: D
Rationale: HRT increases the risk of coronary artery disease. It does not decrease stroke or DVT risk and helps prevent osteoporosis.
A client has received a prescription for lisinopril. The nurse teaches the client that which frequent side effect may occur?
- A. Cough
- B. Polyuria
- C. Hypothermia
- D. Hypertension
Correct Answer: A
Rationale: Cough is a frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors. Fever is an occasional side effect. Proteinuria is another common side effect, but polyuria is not. Hypertension is the reason to administer the medication rather than a side effect.