Nokea
The client has a history of hypertension.
A nurse is caring for a client who has a history of hypertension. Which of the following findings should the nurse recognize is indicative of transient ischemic attacks?
- A. Epigastric pain
- B. Seizure activity
- C. Sudden loss of vision in one eye
- D. Pain radiating down the left arm
Correct Answer: C
Rationale: Sudden monocular vision loss is a classic TIA symptom.
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A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?
- A. Thoroughly explain each procedure to the toddler.
- B. Start the examination with routine immunizations.
- C. Allow the toddler to handle the equipment.
- D. Completely undress the toddler.
Correct Answer: C
Rationale: Allowing the toddler to handle equipment reduces fear and increases cooperation.
A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I should place my baby in the car seat at a 90-degree angle.
- B. I should keep my baby rear-facing in the car seat until she is 2 years old.
- C. I should position the car seat's retainer clip at the level of my baby's belly button.
- D. I should enable the airbag when my baby is in the front seat of the car.
Correct Answer: B
Rationale: Rear-facing until age 2 aligns with current safety guidelines.
The client is in renal failure.
A nurse is collecting data from a client who is in renal failure. Which of the following findings should the nurse identify as a manifestation of hyperkalemia?
- A. Dry mucous membranes
- B. Hyperactive reflexes
- C. Trousseau's sign
- D. Irregular heart rate
Correct Answer: D
Rationale: Irregular heart rate is a hallmark of hyperkalemia due to its effect on cardiac conduction.
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?
- A. Voice alteration
- B. Neck pain
- C. Tingling of the scalp
- D. Temporary memory loss
Correct Answer: D
Rationale: Temporary memory loss is a common side effect post-ECT.
The client is 2 days postpartum and cannot afford to pay for baby formula.
A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?
- A. Primary care provider
- B. Nutritionist
- C. Pediatric nurse practitioner
- D. Case manager
Correct Answer: D
Rationale: A case manager can connect the client to financial resources.