Nokea
A client seeks care for hopeless that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question.
- A. “Do you smoke cigarettes, cigars or pipe?”
- B. “Have you strained your voice recently?”
- C. “Do you eat a lot of red meat?”
- D. “Do you eat spicy foods?”
Correct Answer: B
Rationale: The correct answer is B: “Have you strained your voice recently?” This question is relevant to the client's symptom of hopeless, as vocal strain can contribute to this issue. Asking about voice strain helps to identify a potential cause and guides further assessment and intervention.
Choice A is not directly related to the client's primary concern and does not address the underlying cause of hopeless.
Choice C is unrelated to the client's symptom and does not provide information that is pertinent to addressing the issue at hand.
Choice D is also unrelated to the client's symptom of hopeless and does not address potential contributing factors.
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A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself?
- A. Standing at the end of the bed
- B. Standing at the side of the bed
- C. Sitting at least six feet from the bedside
- D. Sitting at a 45-degree angle to the bed
Correct Answer: D
Rationale: The correct answer is D: Sitting at a 45-degree angle to the bed. This position allows the nurse to have a clear view of the client and maintain good communication. Sitting at a 45-degree angle enables the nurse to observe the client's facial expressions, body language, and interact effectively. Standing at the end of the bed (A) limits the nurse's view and communication. Standing at the side of the bed (B) may obstruct the nurse-client interaction. Sitting at least six feet away (C) creates unnecessary distance and hinders effective communication.
When teaching a client about insulin therapy, the nurse should instruct the client to avoid which over-the- counter preparation that can interact with insulin?
- A. Antacids
- B. Vitamins with irons
- C. Acetaminophen preparations
- D. Salicylate preparations
Correct Answer: D
Rationale: The correct answer is D: Salicylate preparations. Salicylate can potentiate the effects of insulin, leading to hypoglycemia. Therefore, the nurse should instruct the client to avoid this over-the-counter preparation when on insulin therapy. Antacids (A), vitamins with iron (B), and acetaminophen preparations (C) do not typically interact with insulin in a significant way.
Usually, how does the patient behave after his seizure has subsided?
- A. Most comfortable walking and moving about
- B. Sleeps for a period of time
- C. Becomes restless and agitated
- D. Say he is thirsty and hungry
Correct Answer: B
Rationale: The correct answer is B: Sleeps for a period of time. After a seizure, the brain and body experience fatigue and exhaustion. It is common for the patient to feel drowsy and require rest to recover. This post-ictal state is characterized by sleepiness and confusion. The other choices are incorrect because typically, after a seizure, the patient is not most comfortable walking and moving about (A), does not become restless and agitated (C), and may not immediately express thirst and hunger (D). It is important to ensure the patient is in a safe environment and allow them to rest after a seizure episode.
In assessing clients for pernicious anemia, the nurse should be alert for which of the following risk factors?
- A. Positive family history
- B. Infectious agents or toxins
- C. Acute or chronic blood loss
- D. Inadequate dietary intake
Correct Answer: A
Rationale: The correct answer is A: Positive family history. Pernicious anemia is an autoimmune condition where the body attacks its own intrinsic factor, leading to vitamin B12 deficiency. Genetic predisposition plays a significant role in the development of pernicious anemia. Family history is a key risk factor as individuals with a family history of pernicious anemia are more likely to develop the condition.
Summary of why the other choices are incorrect:
B: Infectious agents or toxins do not directly cause pernicious anemia, although they can lead to other types of anemia.
C: Acute or chronic blood loss can result in iron-deficiency anemia, not pernicious anemia.
D: Inadequate dietary intake of vitamin B12 can lead to vitamin B12 deficiency anemia, but pernicious anemia specifically involves the body's inability to absorb B12 due to intrinsic factor deficiency, not dietary intake alone.
Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?
- A. Increased urine output
- B. Dyspnea on exertion
- C. Swollen joints
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B: Dyspnea on exertion. In older clients, dyspnea on exertion is often the earliest symptom of heart failure due to decreased cardiac reserve. This occurs when the heart cannot pump enough blood to meet the body's demands during physical activity. Increased urine output (A) is not typically an early symptom of heart failure. Swollen joints (C) are more indicative of arthritis or inflammation, not necessarily heart failure. Nausea and vomiting (D) are not typical early symptoms of heart failure and are more commonly associated with gastrointestinal issues.