Nokea
A client with a history of chronic migraines is admitted with complaints of headache. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring blood pressure
- C. Providing a quiet environment
- D. Administering oxygen
Correct Answer: C
Rationale: A quiet environment reduces sensory stimuli, which can exacerbate migraines, making it a priority to promote comfort.
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In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:
- A. Becomes progressively debilitating without remission
- B. Has unpredictable remissions and exacerbations
- C. Is rapidly fatal
- D. Responds quickly to antimicrobial therapy
Correct Answer: B
Rationale: Multiple sclerosis eventually becomes debilitating, but it is characterized by remission of symptoms. Remissions and exacerbations are unpredictable with multiple sclerosis. The client experiences progressive dysfunction after each exacerbation episode. Multiple sclerosis is usually slowly progressive. Multiple sclerosis is an autoimmune disease. Antimicrobial therapy has no effect on its course.
The client is admitted with a diagnosis of chorioamnionitis. Which vital sign change is most likely to be observed?
- A. Maternal fever
- B. Tachycardia
- C. Fetal bradycardia
- D. All of the above
Correct Answer: D
Rationale: Chorioamnionitis causes maternal fever (from infection) tachycardia (from systemic response) and fetal bradycardia (from distress). All vital sign changes are likely in this condition.
A client with a history of a hiatal hernia is being taught about dietary management. The nurse should encourage the client to:
- A. Eat large meals
- B. Avoid caffeine
- C. Lie down after meals
- D. Eat high-fat foods
Correct Answer: B
Rationale: Caffeine relaxes the lower esophageal sphincter, worsening hiatal hernia symptoms. Small meals, avoiding lying down post-meals, and low-fat foods are recommended.
The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
- A. Chest drainage of 150 mL in the past hour
- B. Confusion and restlessness
- C. Pallor and coolness of skin
- D. Urinary output of 40 mL per hour
Correct Answer: A
Rationale: Chest drainage of 150 mL/hour post-CABG suggests significant bleeding, requiring immediate reporting to prevent hypovolemia. Confusion, pallor, and low urine output are less urgent.
The client at 34 weeks gestation is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate intervention?
- A. Blood pressure of 150/100
- B. 2+ proteinuria
- C. Absence of deep tendon reflexes
- D. Edema of the lower extremities
Correct Answer: C
Rationale: Absence of deep tendon reflexes in gestational hypertension suggests magnesium toxicity (if receiving magnesium sulfate) or severe neurological complications requiring immediate intervention. The other findings while concerning are less urgent.