Nokea
A client at the family planning clinic requests a prescription for oral contraceptives from the nurse who is performing an assessment. After reviewing the client's chart, the nurse determines that oral contraceptives are contraindicated because of which documented item? (Refer to chart.)
- A. Has renal calculi
- B. Blood pressure: 108 / 72mmHg
- C. Had thrombotic stroke at age 35 years
- D. Apical heart rate: 72 beats/min
Correct Answer: C
Rationale: Oral contraceptives are contraindicated in women with a history of thrombophlebitis and thromboembolic disorders; cardiovascular or cerebrovascular diseases (including stroke [brain attack]); any estrogendependent cancer or breast cancer, or benign or malignant liver tumors; impaired liver function; hypertension; or diabetes mellitus with vascular involvement. Adverse effects of oral contraceptives include increased risk of superficial and deep vein thrombosis, pulmonary embolism, thrombotic stroke (or other types of strokes), myocardial infarction, and accelerations of preexisting breast tumors.
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The nurse is instructing a client diagnosed with type 1 diabetes mellitus about the management of hypoglycemic reactions. The nurse instructs the client that hypoglycemia most likely occurs during what time interval after insulin administration?
- A. Peak
- B. Onset
- C. Duration
- D. Anytime
Correct Answer: A
Rationale: Insulin reactions are most likely to occur during the peak time after insulin administration, when the medication is at its maximum action. Peak action depends on the type of insulin, the amount administered, the injection site, and other factors.
The nurse is reviewing the medication history for a 24-year-old client in the fertility clinic. Which medication does the nurse understand to be a Category X medication in pregnancy?
- A. metformin
- B. amoxicillin
- C. gabapentin
- D. simvastatin
Correct Answer: D
Rationale: Simvastatin is Category X, contraindicated in pregnancy due to fetal harm. Others are safer (Categories B or C).
The nurse instructs a client who is hospitalized and on a low-fat diet. Which menu does the nurse provide for the client?
- A. Shrimp, avocado, and tomato salad
- B. Calf's liver, potato salad, and sherbet
- C. Lean steak, mashed potatoes, and gravy
- D. Turkey breast, boiled rice, and strawberries
Correct Answer: D
Rationale: Turkey breast without the skin, boiled rice, and strawberries offer the client nourishing foods that are low in fat. Some sources of fat include meats, avocado, salad dressing, mayonnaise, butter, cheese, and bacon. The remaining options contain high-fat foods.
The home care nurse suspects that a client's spouse is experiencing caregiver strain. Which action should the nurse take to assess for this condition?
- A. Referring the family to a social services agency
- B. Gathering data from the caregiver and the client
- C. Waiting for the caregiver to talk about the stress
- D. Obtaining feedback from the client about the caregiver
Correct Answer: B
Rationale: Caregiver strain can occur when a client is significantly dependent on the caregiver for personal and health care needs. The nurse gathers data from the client and the caregiver to determine the caregiver's stressors and coping abilities and withholds making any referrals until the assessment is complete and the plan of care is in place. Because the nurse suspects caregiver strain, the nurse fulfills the duty to the client and family by approaching the family with the concern, gathering assessment data, and planning care. The nurse does not expect the client to assess the coping abilities of the caregiver because assessment is part of the nursing process and should not be delegated.
The nurse is performing a socioeconomic assessment of an Asian client. Which questions are appropriate for the nurse to ask?
- A. What do you do for a living?
- B. How much money do you make yearly?
- C. Do you have a primary health care provider?
- D. How many years of school did you complete?
- E. How different is your life here from in your homeland?
- F. What type of work did you do back in your homeland?
Correct Answer: A,C,D,E,F
Rationale: Aspects to include in a cultural assessment include biocultural history and socioeconomic status (distinct health risks can be attributed to the ecological and socioeconomic context of the culture) and the client's country of origin. Other aspects to assess include religious and spiritual beliefs, communication patterns, time orientation, caring beliefs and practices, and previous experiences with professional health care. Some specific questions to ask when performing a socioeconomic assessment are noted in the correct options. Asking the client about his or her yearly income is inappropriate, unnecessary, and unrelated to health care resources.