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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A patient is scheduled for an electromyogram. What should the nurse instruct the patient to do in preparation for this diagnostic test? Select all that apply.
- A. Do not smoke for 3 hours before the test
- B. Avoid taking muscle relaxants before the test
- C. Avoid taking oral hypoglycemic agents before the test
- D. Alert the healthcare provider about an allergy to shellfish e. Avoid fluids containing caffeine for 3 hours before the test
Correct Answer: B
Rationale: B. It is essential for the patient to avoid taking muscle relaxants before the electromyogram test because these medications can affect the results by altering muscle activity and electrical signals, which are critical for diagnosing muscle and nerve disorders.
The community nurse is teaching a class at the community center regarding the cultural and ethnic risk factors for stroke. Which statement should nurse include in this presentation?
- A. Caucasians have an increased incidence of intracerebral hemorrhage.
- B. African Americans have almost twice the number of first-ever strokes compared with Whites.
- C. Asian Americans are more likely to die following a stroke than Whites.
- D. The prevalence of hypertension among Hispanics is the highest in the world.
Correct Answer: B
Rationale: The correct statement that should be included in the presentation is that African Americans have almost twice the number of first-ever strokes compared with Whites. This is based on research and statistics that show African Americans have a higher incidence of stroke compared to other ethnic groups in the United States. It is important for healthcare providers to be aware of these disparities in order to address them effectively through targeted prevention and management strategies. Moreover, raising awareness about these risk factors can help promote early intervention and reduce the burden of stroke within the African American community.
The nurse is providing teaching to a client diagnosed with cardiomyopathy. What statement made by the client indicates the discharge teaching was effective?
- A. "I will exercise as much as possible, regardless of feeling weak and short of breath."
- B. "My pants getting tight around the waist means I'm eating too much and should cut back on food."
- C. "I will eat foods containing sodium only if drinking water with them."
- D. "I will see my cardiologist next week to discuss implanting a pacemaker."
Correct Answer: C
Rationale: The correct statement indicating effective discharge teaching for a client diagnosed with cardiomyopathy is "I will eat foods containing sodium only if drinking water with them." This statement shows the client understands the importance of reducing sodium intake to manage cardiomyopathy effectively. Excess sodium can contribute to fluid retention and worsen symptoms of heart failure, which often accompanies cardiomyopathy. By pairing sodium-containing foods with water, the client can help mitigate the potential negative effects of sodium on their condition. The other options are incorrect as they do not demonstrate an understanding of the condition or appropriate self-care measures.
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.
A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which action is appropriate when providing care based on this nursing diagnosis?
- A. Place the client in low-Fowler position to improve gas exchange
- B. Monitor the client's oxygen saturation intermittently
- C. Encourage frequent amulation
- D. Use continuous endotracheal suctioning instead of coughing and deep breathing
Correct Answer: B
Rationale: Monitoring the client's oxygen saturation intermittently is the most appropriate action when providing care for a client with disseminated intravascular coagulation (DIC) who has a nursing diagnosis of Impaired Gas Exchange. DIC can lead to a variety of complications, including inadequate oxygenation of tissues due to abnormal clotting and bleeding. By monitoring the client's oxygen saturation levels, the healthcare team can assess the effectiveness of gas exchange and adjust interventions as needed to optimize oxygenation. This action helps in early detection of worsening gas exchange and guides appropriate interventions to address any respiratory issues promptly. Placing the client in a low-Fowler position may not be suitable for all patients with DIC, encouraging frequent ambulation could be risky due to the increased bleeding tendency, and using continuous endotracheal suctioning is not recommended as it can lead to aggravation of respiratory issues and increase the risk of further complications.