Nokea
A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time?
- A. Ask about the client's recent bowel and bladder habits
- B. Assess the home for sources of excessive noise
- C. Provide information about respite and adult day care
- D. Review behavior-management techniques with caregiver
Correct Answer: B
Rationale: Assessing for environmental triggers like noise is the priority, as it may contribute to agitation in Alzheimer's. Other actions are secondary.
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The nurse is reinforcing teaching for the parents of a child newly diagnosed with hemophilia. Which long-term complication is important for the nurse to discuss?
- A. Heart valve injury
- B. Intellectual disability
- C. Joint destruction
- D. Recurrent pneumonia
Correct Answer: C
Rationale: Hemophilia causes recurrent joint bleeds, leading to joint destruction (hemophilic arthropathy), a key long-term complication.
A 19-year-old primigravida is admitted for observation due to a sudden increase in blood pressure. The doctor suspects a diagnosis of pregnancy-induced hypertension. Which of the following is considered a significant factor in the development of pregnancy-induced hypertension?
- A. Maternal age
- B. Nutritional status of mother
- C. Pre-pregnant weight
- D. History of hypertension
Correct Answer: D
Rationale: A history of hypertension is a significant risk factor for developing pregnancy-induced hypertension (preeclampsia), as it indicates a predisposition to vascular issues.
The client has a chest tube attached to a portable water seal drainage system. Four hours after the chest tube is inserted, the nurse notes that there is no bubbling in the water seal compartment. What is the most likely explanation for this?
- A. The lung has reexpanded.
- B. There is an obstruction in the tubing coming from the pleural cavity.
- C. There is an air leak in the drainage system.
- D. The suction is not turned on.
Correct Answer: A
Rationale: No bubbling in the water seal four hours post-insertion suggests the lung has reexpanded, resolving the pneumothorax. Obstruction, air leaks, or inactive suction would typically cause other signs.
The nurse is talking with the parent of a 6-year-old client about how to share details of the client's adoption. Which of the following thought processes would be consistent with the expected cognitive development of the client?
- A. feels responsible for being placed for adoption
- B. imagines what life would be like with the biological family
- C. worries about what peers will say or think about being adopted
- D. defies adoptive parents and asks for information about birth parents
Correct Answer: B
Rationale: At age 6, children can imagine scenarios like life with biological parents, consistent with concrete operational thinking. Other options reflect older or atypical development.
The nurse is talking with a client with rheumatoid arthritis who has a new prescription for adalimumab. Which of the following statements by the client would require follow-up?
- A. I usually take naproxen for pain twice a week
- B. I received my annual influenza vaccine injection 3 weeks ago.
- C. I received a negative test result for my tuberculin skin test one week ago.
- D. I started a course of antibiotic therapy to treat a urinary tract infection 2 days ago.
Correct Answer: D
Rationale: Adalimumab, an immunosuppressant, increases infection risk. Starting antibiotics for an active infection requires follow-up to ensure the infection is resolved before initiating adalimumab. The other statements are not concerning.