Nokea
A nurse is assessing a group of clients. Which clients are at risk for vasospastic disorder (Raynaud's phenomenon)?
- A. Young women
- B. Old women
- C. Old men
- D. Young men
Correct Answer: A
Rationale: Young women are at highest risk for Raynaud's phenomenon, particularly primary Raynaud's, due to hormonal influences and higher prevalence of autoimmune conditions. While men and older individuals can develop it, young women are most commonly affected.
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The nurse is developing a care plan with an older adult and is instructing the client that hypertension can be a silent killer. The nurse should instruct the client to be aware of signs and symptoms of other system failures and encourage the client to report signs of which of the following diseases that are often a result of undetected high blood pressure?
- A. Cerebrovascular accidents (CVAs).
- B. Liver disease.
- C. Myocardial infarction.
- D. Pulmonary disease.
Correct Answer: A,C
Rationale: Hypertension increases the risk of cerebrovascular accidents (A) and myocardial infarction (C), as it damages blood vessels, leading to stroke or heart attack.
The nurse is developing a discharge plan about home care with a client who has lymphoma. The nurse should emphasize which of the following?
- A. Use analgesics as needed.
- B. Take a shower with perfumed shower gel.
- C. Wear a mask when outside of the home.
- D. Take an antipyretic every morning.
Correct Answer: A
Rationale: Clients with lymphoma may experience pain from lymph node enlargement or treatment. Using analgesics as needed is appropriate for symptom management. Perfumed shower gel may irritate skin, masks are not routinely needed, and daily antipyretics are unnecessary unless fever persists.
When assessing a client for early septic shock, the nurse observes for which of the following?
- A. Cool, clammy skin.
- B. Warm, flushed skin.
- C. Decreased systolic blood pressure.
- D. Hemorrhage.
Correct Answer: B
Rationale: Early septic shock is characterized by vasodilation and increased cardiac output, leading to warm, flushed skin. Cool, clammy skin and decreased blood pressure occur in later stages, and hemorrhage is not a feature of septic shock.
When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.
- A. Verify patency of the line by the presence of a blood return at regular intervals.
- B. Inspect the insertion site for swelling, erythema, or drainage.
- C. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
- D. If unable to aspirate blood, reposition the client and encourage the client to cough.
- E. Contact the health care provider about verifying placement if the status is questionable.
Correct Answer: A,B,D,E
Rationale: Verifying patency (A), inspecting the site (B), repositioning for no blood return (D), and contacting the provider if placement is questionable (E) are critical to ensure safe chemotherapy administration. Administering without blood return (C) risks extravasation and tissue damage.
The nurse is developing the discharge teaching plan for a client after a lumbar laminectomy L4-5 who will be returning to work in 6 weeks. Which of the following actions should the nurse encourage the client to avoid?
- A. Placing one foot on a stepstool during prolonged standing.
- B. Sleeping on the back with support under the knees.
- C. Maintaining average body weight for height.
- D. Sitting whenever possible.
Correct Answer: D
Rationale: Prolonged sitting can stress the surgical site and delay healing post-laminectomy.