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A home health nurse assesses an older adult with vision loss due to glaucoma. What is a safety hazard?
- A. Bright overhead lighting
- B. Presence of scatter rugs in the kitchen
- C. Using contrasting colors in home decor
- D. Wearing slip-resistant shoes
Correct Answer: B
Rationale: The correct answer is B: Presence of scatter rugs in the kitchen. Scatter rugs pose a tripping hazard for individuals with vision loss, especially in areas like the kitchen where spills and slippery surfaces are common. The other choices are incorrect because: A - Bright overhead lighting can actually be beneficial for those with vision loss by improving visibility; C - Using contrasting colors can aid in distinguishing objects and pathways; D - Wearing slip-resistant shoes can help prevent falls.
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A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?
- A. Dysmenorrhea that is unresponsive to NSAIDs
- B. Heavy menstrual bleeding
- C. Positive family history of fibroids
- D. Pelvic pain after intercourse
Correct Answer: A
Rationale: The correct answer is A: Dysmenorrhea that is unresponsive to NSAIDs. Endometriosis is characterized by severe menstrual pain that is not relieved by NSAIDs. This is due to the abnormal growth of endometrial tissue outside the uterus. Heavy menstrual bleeding (B) is a common symptom but not specific to endometriosis. Positive family history of fibroids (C) is unrelated to endometriosis. Pelvic pain after intercourse (D) can be a symptom of endometriosis but is not as specific as unresponsive dysmenorrhea.
A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide?
- A. Take the medication early in the day.
- B. Take the medication at bedtime.
- C. Take the medication with food.
- D. Take the medication only when blood pressure is high.
Correct Answer: A
Rationale: The correct answer is A: Take the medication early in the day. Hydrochlorothiazide is a diuretic that increases urine production, which can cause frequent urination. Taking it early helps prevent nighttime urination, promoting better sleep. Taking it with food may reduce gastrointestinal upset. Taking it only when blood pressure is high is incorrect, as it should be taken regularly to maintain consistent blood pressure control. Bedtime dosing may lead to nocturnal diuresis and disturb sleep. The other choices are irrelevant or incorrect in the context of hydrochlorothiazide administration.
A nurse is assessing a client with menopausal symptoms considering hormone therapy. What is a contraindication?
- A. History of osteoporosis
- B. History of breast cancer
- C. History of anemia
- D. History of chronic migraines
Correct Answer: B
Rationale: The correct answer is B: History of breast cancer. Hormone therapy can potentially stimulate the growth of breast cancer cells. It is contraindicated in clients with a history of breast cancer due to the increased risk of cancer recurrence or progression. Other choices are incorrect because: A: History of osteoporosis is not a contraindication for hormone therapy, as it can actually help improve bone density. C: History of anemia is not a contraindication for hormone therapy. D: History of chronic migraines is not a contraindication, but it may need monitoring as hormone therapy can sometimes trigger migraines.
A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
- A. Output of dark amber urine
- B. Output of clear, light pink urine
- C. Output of bright red urine
- D. Output of burgundy colored urine
Correct Answer: D
Rationale: The correct answer is D: Output of burgundy colored urine. This indicates possible hemorrhage, a serious complication post-TURP. Dark amber urine (A) may suggest dehydration. Clear, light pink urine (B) is expected due to bladder irrigation post-TURP. Bright red urine (C) is common initially but should decrease over time. Burgundy colored urine (D) indicates active bleeding and requires immediate intervention.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.