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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Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply.
- A. Slight increase in pulse
- B. Dry, warm skin
- C. Increased urine output
- D. Normal respirations
Correct Answer: A
Rationale: A. A slight increase in pulse is a common finding in hypovolemic shock. The body compensates for the decreased blood volume by increasing the heart rate to maintain adequate perfusion.
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 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.
During a blood pressure screening, an older adult client tells the nurse about chest fluttering while doing yard work. The client reports no other symptoms and the frequency is intermittent. Which action is correct by the nurse?
- A. Suggest the client stop exercising
- B. Reassure these are normal changes associated with aging
- C. Ensure the client is evaluated by his/her medical provider
- D. Check laboratory values for hypothyroidism
Correct Answer: C
Rationale: The correct action for the nurse in this situation would be to ensure the client is evaluated by his/her medical provider. Chest fluttering, also known as palpitations, can sometimes be related to cardiac arrhythmias, which can be a concern in older adults. Even though the client reports no other symptoms and the frequency is intermittent, it is essential for the medical provider to assess and determine the cause of the fluttering to rule out any serious underlying cardiac issues. Taking appropriate action promptly can help prevent any potential complications and ensure the client's well-being.
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.