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A nurse is caring for a client who has hypertension and is receiving enalapril. Which of the following findings should the nurse report to the provider?
- A. Increased heart rate
- B. Persistent cough
- C. Constipation
- D. Sweating
Correct Answer: B
Rationale: The correct answer is B: Persistent cough. Enalapril is an ACE inhibitor that can cause a persistent cough as a common side effect. This symptom should be reported to the healthcare provider to evaluate if a medication adjustment is needed. Choices A, C, and D are not typically associated with enalapril use and are less likely to be directly related to the medication. Increased heart rate, constipation, and sweating are not commonly linked to enalapril, so they are not the priority findings to report in this case.
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A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration?
- A. Haloperidol
- B. Zolpidem
- C. Morphine
- D. Lorazepam
Correct Answer: B
Rationale: The correct answer is B: Zolpidem. Zolpidem is a sedative-hypnotic medication that can worsen altered mental status, especially in clients who are already aggressive. Therefore, the nurse should clarify this prescription with the provider before administration to ensure it is safe for the client.
Choice A, Haloperidol, is an antipsychotic commonly used to manage aggression in clients with altered mental status, making it an appropriate choice in this scenario. Choice C, Morphine, is an opioid analgesic and would not directly impact the client's altered mental status or aggression. Choice D, Lorazepam, is a benzodiazepine used to manage anxiety and agitation, which could be beneficial in this situation but does not have the same potential to exacerbate altered mental status as Zolpidem.
A nurse is caring for a client following an acute myocardial infarction who is concerned about fatigue. What is the best strategy to promote independence in self-care?
- A. Instruct the client to remain in bed until the fatigue resolves
- B. Encourage the client to gradually resume self-care tasks with frequent rest periods
- C. Assign assistive personnel to perform all self-care tasks for the client
- D. Ask the client's family to assist with self-care
Correct Answer: B
Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence while managing fatigue. This approach allows the client to regain confidence in their abilities and fosters independence. Option A is incorrect as prolonged bed rest can lead to deconditioning and worsen fatigue. Option C is not promoting independence as it involves delegating all self-care tasks to others. Option D involves family assistance, which may be helpful but does not directly promote the client's independence in self-care.
Which intervention is essential when caring for a client with heart failure on fluid restriction?
- A. Encourage the client to drink water throughout the day
- B. Monitor the client's weight daily to assess fluid balance
- C. Limit fluid intake during meals
- D. Weigh the client once a week to assess fluid balance
Correct Answer: B
Rationale: The correct answer is B: 'Monitor the client's weight daily to assess fluid balance.' When caring for a client with heart failure on fluid restriction, it is essential to monitor their weight daily to evaluate fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink water throughout the day contradicts fluid restriction. Limiting fluid intake during meals may not provide a comprehensive assessment of fluid balance, and weighing the client once a week is not frequent enough to detect rapid changes in fluid status that could worsen heart failure symptoms.
What are the major risk factors for stroke?
- A. Hypertension, high cholesterol, and smoking
- B. Obesity and lack of exercise
- C. Family history of cardiovascular disease
- D. Age and gender
Correct Answer: A
Rationale: The correct answer is A: Hypertension, high cholesterol, and smoking are major risk factors for stroke. These factors contribute to the development of atherosclerosis, which can lead to a stroke. While obesity and lack of exercise are risk factors for cardiovascular diseases, they are not as directly linked to stroke as hypertension, high cholesterol, and smoking. Family history of cardiovascular disease may increase the overall risk of heart problems, but it is not as specific to stroke as the factors listed in option A. Age and gender can influence the risk of stroke, but they are not modifiable risk factors like hypertension, high cholesterol, and smoking, which can be reduced through lifestyle changes.
A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?
- A. Iron 90 mcg/dl.
- B. Prealbumin 10 mcg/dl.
- C. Serum creatinine 0.8 mg/dl.
- D. Calcium 9.5 mg/dl.
Correct Answer: B
Rationale: Corrected Rationale: Low prealbumin levels are indicative of malnutrition, which is common in individuals with anorexia nervosa. Iron levels, serum creatinine, and calcium levels are not typically affected in the same way by anorexia nervosa, making choices A, C, and D incorrect.