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A nurse is assessing a client with hyperemesis gravidarum. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Diplopia
- C. Hypoglycemia
- D. Dizziness
Correct Answer: A
Rationale: The correct answer is A: Oliguria. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, leading to dehydration and electrolyte imbalances. Oliguria, decreased urine output, is expected due to dehydration. Diplopia (B) and dizziness (D) are not specific to hyperemesis gravidarum. Hypoglycemia (C) may occur due to poor oral intake but is not a defining feature.
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A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks?
- A. Keeping a promise to visit a client who is housebound after the delivery of care.
- B. Ensuring that a client who is homeless receives preventive medical care.
- C. Being honest with the parents of a child about the need to report suspected abuse.
- D. Accepting the decision of an older adult client to live alone in her home.
Correct Answer: B
Rationale: The correct answer is B. Distributive justice refers to fair distribution of resources and services to all individuals, with priority given to those in need. By ensuring that a homeless client receives preventive medical care, the nurse is upholding this principle. This action promotes equity and fairness by addressing the health needs of a vulnerable population.
A: Keeping a promise to visit a housebound client is important for maintaining trust and continuity of care, but it does not directly relate to distributive justice.
C: Being honest about reporting suspected abuse is related to ethical duty and integrity, not distributive justice.
D: Accepting an older adult's decision to live alone respects autonomy and independence, but it is not directly tied to distributive justice.
A client states, 'My life has no meaning right now.' What is the nurse's best response?
- A. Have you been thinking about harming yourself?
- B. How long have you been feeling this way?
- C. Tell me what is going on with you right now.
- D. Do you really think your life has no purpose?
Correct Answer: A
Rationale: The correct answer is A. By asking the client if they have been thinking about harming themselves, the nurse is directly addressing the potential risk of suicide, which is crucial when a client expresses feelings of hopelessness. This question helps assess the client's safety and determine the need for immediate intervention. Choices B, C, and D are not as direct in addressing the potential risk of self-harm and may not provide the necessary urgency in ensuring the client's safety. Asking about self-harm is critical in assessing the severity of the client's distress and ensuring appropriate interventions are implemented promptly.
A nurse is providing teaching to a 50-year-old female client. Which of the following statements should the nurse include in the teaching?
- A. You should have a complete eye examination every 2 years until the age of 64
- B. You should have your hearing screened every 5 years
- C. You should have your stool tested for blood every other year until the age of 74
- D. You should have your fasting blood glucose level checked every 6 years
Correct Answer: A
Rationale: Correct Answer: A - You should have a complete eye examination every 2 years until the age of 64.
Rationale: Regular eye exams help detect common eye conditions such as glaucoma and cataracts early, especially as people age. The American Academy of Ophthalmology recommends eye exams every 2 years for adults aged 40-64. This statement is important for the client's eye health maintenance.
Summary of other choices:
B: Incorrect - Hearing screenings are typically recommended annually for adults over 50, not every 5 years.
C: Incorrect - Stool tests for blood are usually done every year, not every other year until the age of 74, to screen for colorectal cancer.
D: Incorrect - Fasting blood glucose levels should be checked more frequently, at least every 3 years, for early detection of diabetes.
A nurse is planning a priority intervention to reduce obesity in the community. Which of the following actions should the nurse take?
- A. Encourage enrollment and attendance at weight reduction programs
- B. Educate children at a daycare center about nutrition and exercise
- C. Distribute health risk appraisal questionnaires at community functions
- D. Measure the BMI of older adults at a community senior center
Correct Answer: B
Rationale: The correct answer is B: Educate children at a daycare center about nutrition and exercise. This is the priority intervention because educating children about nutrition and exercise can help prevent obesity in the long term. By teaching healthy habits early on, the nurse can make a significant impact on reducing obesity rates in the community. Encouraging enrollment in weight reduction programs (A) may help individuals who are already obese but does not address prevention. Distributing health risk appraisal questionnaires (C) and measuring BMI of older adults (D) are important but not the priority for reducing obesity in the community.
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
- A. A client who is receiving heparin for deep-vein thrombosis.
- B. A client who is 1 day postoperative following a vertebroplasty.
- C. A client who has cancer and a sealed implant for radiation therapy.
- D. A client who has COPD and a respiratory rate of 44/min.
Correct Answer: B
Rationale: The correct choice is B: A client who is 1 day postoperative following a vertebroplasty. This client is the most stable among the options provided. Early discharge is appropriate because the client is 1 day postoperative, likely past the critical immediate postoperative period. Discharging this client will create space for incoming emergency admissions. Choice A should not be discharged early as managing deep-vein thrombosis with heparin requires close monitoring to prevent complications. Choice C should not be discharged early due to the need for ongoing cancer treatment. Choice D should not be discharged early as the client with COPD and a high respiratory rate of 44/min requires close monitoring and intervention to prevent respiratory distress.