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A client with rheumatoid arthritis reports morning stiffness. Which intervention should the nurse recommend?
- A. Apply cold packs to joints
- B. Perform vigorous exercise upon waking
- C. Take a warm shower in the morning
- D. Avoid all physical activity
Correct Answer: C
Rationale: A warm shower in the morning increases blood flow and reduces joint stiffness, a common symptom of rheumatoid arthritis.
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The nurse is assessing a client with suspected hypovolemic shock. Which finding is most indicative?
- A. Tachycardia
- B. Hypertension
- C. Warm, dry skin
- D. Bradypnea
Correct Answer: A
Rationale: Tachycardia is an early sign of hypovolemic shock as the body compensates for reduced blood volume by increasing heart rate.
A client tells the nurse that her bra fits more snugly at certain times of the month and she is concerned this may be a sign of breast cancer. The best response for the nurse is to explain that:
- A. A change in breast size should be checked by her physician.
- B. Benign cysts tend to cause the breast to vary in size.
- C. It is normal for the breast to increase in size before menstruation begins.
- D. A difference in the size of her breasts is related to normal growth and development.
Correct Answer: C
Rationale: Breast size increases before menstruation due to hormonal changes, which is normal.
A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, 'He is doing too much. I told him to let me help, but he won't let me.' The nurse says to the wife, 'It sounds like you need to feel you can be more helpful to him.' In order to make her nonverbal behavior complement her words, the nurse should:
- A. Direct the eyes at the client.
- B. Direct the body and eyes at the wife and client.
- C. Avoid direct eye contact with the client and wife.
- D. Shift the eyes back and forth between the client and wife.
Correct Answer: B
Rationale: Directing body and eyes to both the wife and client shows engagement and inclusivity, complementing the empathetic verbal response.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances?
- A. Respiratory acidosis.
- B. Respiratory alkalosis.
- C. Metabolic acidosis.
- D. Metabolic alkalosis.
Correct Answer: A
Rationale: COPD with pneumonia can impair gas exchange, leading to CO2 retention and respiratory acidosis.
A client with a history of heart failure is prescribed carvedilol (Coreg). The nurse should instruct the client to:
- A. Monitor blood pressure regularly.
- B. Take the medication with meals.
- C. Avoid potassium-rich foods.
- D. Stop the medication if dizziness occurs.
Correct Answer: A
Rationale: Carvedilol can cause hypotension, requiring regular blood pressure monitoring.