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A nurse is caring for a client who has a new diagnosis of Sjögren's syndrome. Which of the following findings should the nurse expect?
- A. Dry eyes
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Dry eyes are a hallmark symptom of Sjögren's syndrome due to decreased tear production from autoimmune gland dysfunction.
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A nurse is collecting data from a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following findings should the nurse expect?
- A. The client reports a tightening of her abdomen.
- B. The client reports increased urinary output.
- C. The client reports a temperature of 38.9°C (102°F).
- D. The client reports seeing bright red blood.
Correct Answer: A
Rationale: A tightening of the abdomen indicates uterine contractions, a hallmark of preterm labor, which the nurse should expect at 32 weeks of gestation.
A nurse is reinforcing discharge teaching with a client who states, 'I don't feel confident driving to my follow-up appointments.' The nurse should obtain a referral for which of the following members of the health care team?
- A. Physical therapist
- B. Primary care provider
- C. Occupational therapist
- D. Social worker
Correct Answer: D
Rationale: Referring to a social worker is correct. Social workers help clients identify resources, such as transportation services, to ensure they can attend medical appointments and access necessary care.
A nurse is caring for an adolescent who states, 'I joined the track and field team, so I won't argue with my brothers anymore.' The nurse should identify that the client is using which of the following defense mechanisms?
- A. Denial
- B. Sublimation
- C. Regression
- D. Repression
Correct Answer: B
Rationale: Sublimation is correct. Sublimation is the process of channeling unacceptable impulses (such as frustration or aggression) into socially acceptable activities (such as sports or creative pursuits). By joining the track and field team instead of arguing with his brothers, the adolescent is redirecting energy into a positive outlet.
A nurse is caring for a client who has a new prescription for isosorbide mononitrate. Which of the following adverse effects should the nurse monitor for?
- A. Headache
- B. Weight gain
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Isosorbide mononitrate, a nitrate, commonly causes headaches due to vasodilation, especially when starting therapy.
A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?
- A. Limit the number of choices for the client.
- B. Use written signs to assist the client with locating the bathroom.
- C. Provide a stimulating environment for the client.
- D. Use confrontation to manage the client's behavior.
Correct Answer: A
Rationale: Limiting the number of choices for the client is correct. Clients with Alzheimer's disease can become overwhelmed by too many options. Offering simple choices, such as 'Would you like tea or juice?' instead of an open-ended question, helps reduce confusion and frustration.