Nokea
A home care nurse is assessing a client who is prescribed prazosin. Which statement by the client would support the need for further teaching regarding medication compliance?
- A. If I feel dizzy, I'll skip my dose for a few days.
- B. I can't see the numbers on the label to know how much salt is in the food.
- C. I understand why I have to keep taking the pills even when my blood pressure is normal.
- D. If I have a cold, I shouldn't take any over-the-counter remedies without consulting my doctor.
Correct Answer: A
Rationale: Prazosin is used to treat hypertension. The side effects of prazosin are dizziness and impotence. The client needs to be instructed to call the primary health care provider if these side effects occur. Holding (skipping) medication will cause an abrupt rise in blood pressure. Option 2 indicates difficulty taking care of oneself. The remaining options indicate client understanding regarding the medication.
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A child is admitted to the pediatric unit with a diagnosis of acute gastroenteritis. The nurse monitors the child for signs of hypovolemic shock as a result of fluid and electrolyte losses that have occurred in the child. Which finding would indicate the presence of compensated shock?
- A. Bradycardia
- B. Hypotension
- C. Profuse diarrhea
- D. Capillary refill time greater than 2 seconds
Correct Answer: D
Rationale: Shock may be classified as compensated or decompensated. In compensated shock, the child becomes tachycardic in an effort to increase the cardiac output. The blood pressure remains normal. The capillary refill time may be prolonged and more than 2 seconds, and the child may become irritable as a result of increasing hypoxia. The most prevalent cause of hypovolemic shock is fluid and electrolyte losses associated with gastroenteritis. Diarrhea is not a sign of shock; rather, it is a cause of the fluid and electrolyte imbalance.
At the last vaginal exam, the client who is in the late first stage of labor was fully effaced, 8 cm dilated, vertex presentation, and station -1. Which observation would indicate that the fetus was in fetal distress?
- A. The fetal heart rate slowly drops to 110 beats/min during strong contractions, recovering to 138 beats/min immediately afterward.
- B. Fresh meconium is found on the examiner's gloved fingers after a vaginal exam, and the fetal monitor pattern remains essentially unchanged.
- C. Fresh, thick meconium is passed with a small gush of liquid, and the fetal monitor shows late decelerations with a variable descending baseline.
- D. The vaginal exam continues to reveal some old meconium staining, and the fetal monitor demonstrates a U-shaped pattern of deceleration during contractions, recovering to a baseline of 140 beats/min.
Correct Answer: C
Rationale: Meconium staining alone is not a sign of fetal distress. Meconium passage is a normal physiological function that is frequently noted with a fetus of more than 38 weeks' gestation. Fresh meconium, in combination with late decelerations and a variable descending baseline, is an ominous signal of fetal distress caused by fetal hypoxia. It is not unusual for the fetal heart rate to drop to less than the 140 to 160 beats/min range in late labor during contractions, and, in a healthy fetus, the fetal heart rate will recover between contractions. Old meconium staining may be the result of a prenatal trauma that is resolved.
The nurse is developing a plan of care for a client in Buck's (extension) traction. The nurse should determine that which is a priority client problem?
- A. Immobility
- B. Risk of infection
- C. Altered independence
- D. Insufficient sensory stimulation
Correct Answer: A
Rationale: The priority client problem in Buck's traction is immobility. Options 3 and 4 may also be appropriate for the client in traction, but immobility presents the greatest risk for the development of complications. Buck's traction is a skin traction, and there are no pin sites.
The home care nurse is preparing to visit a client diagnosed with Ménière's disease. The nurse reviews the primary health care provider prescriptions and expects to educate the client on which dietary measure?
- A. A low-fiber diet with decreased fluids
- B. A low-sodium diet and fluid restriction
- C. A low-fat diet with a restriction of citrus fruits
- D. A low-carbohydrate diet and the elimination of red meats
Correct Answer: B
Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for clients with Ménière's disease. None of the remaining options are prescribed for this disorder.
The nurse interprets that which observation is related to the dysfunction of cranial nerve III (oculomotor nerve)?
- A. Mild drowsiness
- B. Unilateral ptosis
- C. Diminished mental acuity
- D. Less frequent spontaneous speech
Correct Answer: B
Rationale: Ptosis of the eyelid is caused by pressure on and the dysfunction of cranial nerve III, the oculomotor nerve. The remaining options identify early signs of a deteriorating level of consciousness.