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A client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the nurse?
- A. Dizziness on standing
- B. Fasting blood glucose of 180 mg/dL (10.0 mmol/L)
- C. Presence of muscle cramps
- D. Sunburn on both arms
Correct Answer: A
Rationale: Dizziness on standing suggests orthostatic hypotension, a serious side effect of chlorthalidone, which can lead to falls. Elevated glucose and muscle cramps are concerning but less urgent, and sunburn is unrelated.
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The nurse is assessing a 16-year-old mother for potential child abuse. Which factor is most important when assessing the potential for child abuse?
- A. Age of the mother
- B. Marital status
- C. Socioeconomic status
- D. Abuse as a child
Correct Answer: D
Rationale: A history of being abused as a child is the strongest predictor of potential child abuse, as it influences parenting behaviors.
The nurse is caring for a client who is scheduled for a cardiac stress test tomorrow. Prior to the stress test, the nurse should:
- A. encourage the client to eat a hearty meal just before the test.
- B. not give the client caffeine to drink.
- C. have the client practice by walking vigorously around the unit.
- D. not let the client watch stressful programs on television.
Correct Answer: B
Rationale: Caffeine can affect heart rate and test results, so it should be avoided before a stress test.
The practical nurse is assisting the registered nurse in performing well-child examinations in a pediatric clinic. Which finding requires further evaluation?
- A. Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant
- B. Lateral curvature to the spine noted on examination of a 10-year-old girl
- C. Presence of an S3 heart sound in a 2-year-old
Correct Answer: B
Rationale: Lateral curvature of the spine in a 10-year-old suggests scoliosis, which requires further evaluation to prevent progression. A rounded chest in infants is normal due to developing lungs, and an S3 heart sound can be normal in young children.
An adult who is being admitted to the medical floor with a bleeding ulcer exhibits all of the following. Which finding suggests that the client may be experiencing alcohol withdrawal symptoms?
- A. BP=90/60
- B. Dizziness
- C. Tremors
- D. Pallor
Correct Answer: C
Rationale: Tremors are a classic sign of alcohol withdrawal, distinguishing it from bleeding ulcer symptoms like hypotension, dizziness, or pallor.
The nurse has attended a staff education program about ethical practices in nursing. Which of the following statements by the nurse would indicate a correct understanding of the program? Select all that apply.
- A. Accountability is notifying the health care provider after making a medication error.
- B. Autonomy is informing the client of the care decisions the family has made for the client.
- C. Confidentiality is respecting a client's request to keep suicidal ideation a secret from other members of the health care team.
- D. Fidelity is returning to the client's room with pain medication at the time that was promised to the client.
- E. Nonmaleficence is reporting suspected elder abuse of a client with Alzheimer disease.
Correct Answer: A,D,E
Rationale: Accountability involves taking responsibility for errors (A). Fidelity is keeping promises, such as timely medication delivery (D). Nonmaleficence includes preventing harm by reporting abuse (E). Autonomy respects the client's decision-making, not family decisions (B), and confidentiality does not extend to withholding suicidal ideation, which requires intervention (C).