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A health care provider has just inserted nasal packing for a client with epistaxis. The client is taking ramipril (Altace) for hypertension. What should the nurse instruct the client to do?
- A. Use 81 mg of aspirin daily for relief of discomfort.
- B. Omit the next dose of ramipril (Altace).
- C. Remove the packing if there is difficulty swallowing.
- D. Avoid rigorous aerobic exercise.
Correct Answer: D
Rationale: Avoiding rigorous aerobic exercise prevents increased blood pressure, which could worsen epistaxis. Aspirin increases bleeding risk. Omitting ramipril is not indicated without physician guidance. Removing packing is unsafe and should be done by a healthcare provider.
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The client with vasospastic disorder (Raynaud's phenomenon) complains of cold and numbness in her fingers. The nurse assesses the client for effects of vasoconstriction. Which of the following is an early sign of vasoconstriction?
- A. Cyanosis
- B. Gangrene
- C. Pallor
- D. Rubor
Correct Answer: C
Rationale: Pallor is an early sign of vasoconstriction in Raynaud's, as reduced blood flow causes the skin to turn white. Cyanosis occurs later with prolonged ischemia, gangrene is a late complication, and rubor (redness) occurs during the hyperemic phase after vasospasm resolves.
On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for:
- A. Limited motion of joints.
- B. Deformed joints of the hands.
- C. Early morning stiffness.
- D. Rheumatoid nodules.
Correct Answer: C
Rationale: Early morning stiffness is a hallmark symptom of rheumatoid arthritis, especially in the early stages, as it reflects joint inflammation that worsens after periods of inactivity.
Which of the following guidelines reflects the current American Cancer Society recommendations for screening for colon cancer in individuals who are not at high risk?
- A. Annual digital rectal examination should begin at age 40.
- B. Annual fecal testing for occult blood should begin at age 50.
- C. Individuals should obtain a baseline barium enema at age 40.
- D. Individuals should obtain a baseline colonoscopy at age 45.
Correct Answer: B
Rationale: Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they recommend the nurse to the need for such diagnostic testing, or are considered to be at high risk. CN: Health promotion and maintenance; CL: Apply
A client on hemodialysis reports fatigue. The nurse should assess for:
- A. Anemia.
- B. Hyperkalemia.
- C. Dehydration.
- D. Infection.
Correct Answer: A
Rationale: Anemia is common in renal failure due to decreased erythropoietin.
The sense of hearing is assessed using which standardized test?
- A. Taylor test
- B. Rinne test
- C. Babinski test
- D. APGAR test
Correct Answer: B
Rationale: The Rinne test assesses hearing by comparing air and bone conduction using a tuning fork. The Taylor test is not a standard hearing test, the Babinski test evaluates neurological reflexes, and the APGAR test assesses newborn health.