Nokea
A client with a history of atrial fibrillation is admitted with complaints of palpitations. The nurse should expect the client to have:
- A. Irregular pulse
- B. Bradycardia
- C. Hypertension
- D. Chest pain
Correct Answer: A
Rationale: Atrial fibrillation causes an irregular pulse due to disorganized atrial contractions, a hallmark of the condition.
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The nurse is caring for a client with a history of cirrhosis. Which dietary restriction is most important?
- A. Low fat
- B. Low protein
- C. Low sodium
- D. Low carbohydrate
Correct Answer: C
Rationale: Low sodium is critical in cirrhosis to reduce fluid retention and ascites caused by portal hypertension and hypoalbuminemia. Protein is moderated but not severely restricted, and fat and carbohydrates are less critical.
The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
- A. Reduce his anxiety
- B. Avoid going to psychotherapy
- C. Manipulate the health team members
- D. Increase his self-image by showing higher standards than the fellow clients
Correct Answer: A
Rationale: These behaviors are attempts to relieve anxiety, as compulsive actions often serve as a coping mechanism for severe anxiety.
A client with a history of heart failure is receiving Carvedilol (Coreg). The nurse should monitor the client for:
- A. Hypotension
- B. Hyperglycemia
- C. Tachycardia
- D. Weight gain
Correct Answer: A
Rationale: Carvedilol, a beta-blocker, can cause hypotension due to vasodilation and reduced heart rate. Hyperglycemia, tachycardia, and weight gain are not primary concerns.
The nurse is caring for a client in labor. The fetal monitor shows early decelerations. The nurse should:
- A. Notify the physician immediately
- B. Reposition the client to her left side
- C. Continue to monitor the fetal heart rate
- D. Administer oxygen at 8-10 liters per minute
Correct Answer: C
Rationale: Early decelerations are benign caused by fetal head compression during contractions and do not indicate fetal distress. Continuing to monitor the fetal heart rate is appropriate. Repositioning oxygen or notifying the physician are unnecessary unless other abnormalities occur.
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
- A. Bleeding, bruising, and hemorrhage
- B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
- C. Pain, pallor, pulselessness, paresthesia, and paralysis
- D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
Correct Answer: C
Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.