Nokea
A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?
- A. Weight gain of 2 pounds or more in a 48 hour period
- B. Urinating 4 to 5 times each day
- C. A significant decrease in appetite
- D. Appearance of non-pitting ankle edema
Correct Answer: A
Rationale: Weight gain of 2 pounds or more in a 48 hour period. It is critical for clients to report and be treated for rapid weight gain, which indicates fluid retention and worsening heart failure.
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The nurse is caring for a client with a history of stroke.
- A. Which intervention is most effective for preventing aspiration in a client with a history of stroke?
- B. Thicken liquids to a nectar consistency.
- C. Encourage small, frequent meals.
- D. Place the client in a supine position for meals.
- E. Administer an antiemetic before meals.
Correct Answer: A
Rationale: Thickening liquids to a nectar consistency slows swallowing, reducing aspiration risk in stroke patients with dysphagia. Small meals help, supine positioning increases risk, and antiemetics are irrelevant.
The nurse assesses the development of a three-month-old boy in the well-baby clinic.
- A. Which behavior in a three-month-old boy would be unexpected?
- B. The boy holds his head erect when sitting on the examination table.
- C. The boy tries to grasp a toy just out of reach.
- D. The boy turns his head to try to locate a sound.
- E. The boy smiles spontaneously when he sees his mother.
Correct Answer: B
Rationale: Grasping for objects out of reach is unexpected until around 6 months of age. Holding the head erect, turning toward sounds, and spontaneous smiling are developmentally appropriate for a three-month-old.
A victim of domestic violence states to the nurse, 'If only I could change and be how my companion wants me to be, I know things would be different.' Which would be the best response by the nurse?
- A. The violence is temporarily caused by unusual circumstances, don't stop hoping for a change.
- B. Perhaps, if you understood the need to abuse, you could stop the violence.
- C. No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?
- D. Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do.
Correct Answer: D
Rationale: Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do. This clarifies that the abuser is responsible for the violence.
The nurse is caring for a client who is terminally ill. Upon admission, the client signed advance directives indicating that she does not wish to have any resuscitative measures. The client is now in and out of consciousness. Her daughter comes to the nurse and says, 'I want everything done for my mother if she stops breathing.' How should the nurse respond?
- A. Remove the 'Do Not Resuscitate' order from the chart.
- B. Discuss the client's advance directives with the daughter.
- C. Have the daughter sign a consent form since her mother is in and out of consciousness.
- D. When the client is conscious, ask her again what her wishes are.
Correct Answer: B
Rationale: Discussing advance directives respects the client's documented wishes, clarifying the DNR order with the daughter to ensure alignment.
The client is discharged from the unit with a prescription for Evista (raloxifene HCl). Which of the following is a side effect of this medication?
- A. Leg cramps
- B. Hot flashes
- C. Urinary frequency
- D. Cold extremities
Correct Answer: B
Rationale: Evista, used for osteoporosis, has an estrogen agonist effect, commonly causing hot flashes. It does not cause leg cramps , urinary frequency , or cold extremities .