Nokea
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
- A. Teach the client to develop a plan for daily structured activities.
- B. Encourage the client to exercise.
- C. Suggest that the client develop a list of pleasurable activities.
- D. Provide education on methods to enhance sleep.
Correct Answer: A
Rationale: Structured daily activities provide purpose and combat psychomotor retardation and lack of motivation, key to restoring function.
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A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use an incentive spirometer.
- B. Monitor the urinary stream for the decrease in output.
- C. Report when hematuria becomes pink-tinged.
- D. Restrict physical activities.
Correct Answer: C
Rationale: Reporting pink-tinged hematuria is critical to monitor for complications post-TUNA. Spirometry, urinary stream monitoring, and activity restriction are not specific to TUNA discharge.
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?
- A. Bradycardia and bradypnea.
- B. Stimulation and dilated pupils.
- C. Hallucinations and delusions.
- D. Lethargy and depression.
Correct Answer: B
Rationale: Cocaine, a stimulant, typically causes stimulation, increased heart rate, and dilated pupils. Bradycardia/bradypnea, hallucinations/delusions, or lethargy/depression are less common or associated with withdrawal/overdose.
During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)
- A. Measure the client's blood pressure in both arms.
- B. Screen for a family history of diabetes mellitus.
- C. Arrange for immediate transport to a medical facility.
- D. Advise the client to restrict fluids and keep feet elevated.
- E. Discuss the importance of a regular exercise program.
Correct Answer: A,B,E
Rationale: Measuring blood pressure assesses hypertension risk, screening for diabetes history addresses increased risk from obesity, and discussing exercise helps manage obesity-related risks. Immediate transport is not indicated, and fluid restriction/elevation is irrelevant without edema.
History and Physical
Laboratory Results
Imaging Studies
Initial vital signs
Vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in her arms and legs, and lightheadedness following 3 days of Illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis.
On further assessment, the client reports that her doctor had recently started her on Lisinopril for blood pressure control but it "doesn't seem to help". She then complained of some chest discomfort. The client is moved to an ED room and another set of vital signs is performed. Physician notified and orders received.
Select the client actions that were effective in her treatment.
- A. Denies cramps, weakness, or nausea
- B. BP 116/68 mm Hg, HR 75 bpm
- C. Potassium level 3.6 mEq/L (3.6 mmol/L)
- D. Verbalizes commitment to dialysis appointments
- E. Client states that she will need to resume her Lisinopril to control blood pressure
- F. The client is eager to add dark green vegetables and potatoes to her diet
Correct Answer: B,C,D
Rationale: Stable BP/HR, normal potassium, and dialysis commitment indicate effective treatment. Denying symptoms needs investigation, resuming Lisinopril requires provider guidance, and high-potassium foods are inappropriate.
History and Physical
Initial vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had poor appetite and was not able to go for her scheduled dialysis 2
Based on the client's subjective and objectives data, the nurse recognizes that she is having signs and symptoms of a sinus tachycardiahyperkalemiahypermagnesemiahypokalemia.
- A. Sinus tachycardia
- B. Hyperkalemia
- C. Hypermagnesemia
- D. Hypokalemia
Correct Answer: B
Rationale: The client's history of ESRD, missed dialysis, and symptoms (muscle cramps, tingling, weakness) suggest hyperkalemia, which can cause cardiac arrhythmias like sinus tachycardia. Other options are less consistent with the clinical picture.