Nokea
A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.)
- A. Shallow respirations
- B. Cardiac dysrhythmias
- C. Flushing
- D. Hyperactive reflexes
- E. Abdominal pain
Correct Answer: A,B,D
Rationale: The correct answer is A, B, and D. In metabolic alkalosis, the blood pH is elevated due to an excess of bicarbonate. Shallow respirations (A) occur as a compensatory mechanism to retain CO2 and decrease pH. Cardiac dysrhythmias (B) can result from electrolyte imbalances associated with alkalosis. Hyperactive reflexes (D) are a sign of neuromuscular irritability due to altered electrolyte levels. Flushing (C) and abdominal pain (E) are not typically associated with metabolic alkalosis. In summary, the nurse should monitor for shallow respirations, cardiac dysrhythmias, and hyperactive reflexes in a client with metabolic alkalosis, as they are indicative of the condition and its complications.
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A nurse is assisting with the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include in the plan?
- A. Ensure that a family member is present who can interpret health care information.
- B. Use pictures to reinforce instructions given to the client.
- C. Speak in a loud voice when talking to the client.
- D. Encourage the client to nod to indicate understanding.
Correct Answer: B
Rationale: Using pictures as reinforcement supports effective communication and understanding.
A nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?
- A. 108/60 mm Hg
- B. 128/88 mm Hg
- C. 154/96 mm Hg
- D. 164/104 mm Hg
Correct Answer: C
Rationale: The correct answer is C (154/96 mm Hg) for stage 1 hypertension. Stage 1 hypertension is defined as systolic blood pressure ranging from 130-139 mm Hg or diastolic blood pressure ranging from 80-89 mm Hg. Option C falls within this range, making it the correct choice. Option A (108/60 mm Hg) is normal blood pressure. Option B (128/88 mm Hg) is prehypertension. Option D (164/104 mm Hg) falls within the stage 2 hypertension range, which is higher than stage 1 hypertension.
A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?
- A. To regulate blood pressure
- B. To promote digestion
- C. To enhance the immune system
- D. To reduce inflammation
Correct Answer: B
Rationale: The correct answer is B: To promote digestion. Ginger tea is commonly used in Chinese culture to aid digestion and alleviate gastrointestinal issues, making it a suitable choice for a client recovering from a bowel obstruction. Ginger has natural properties that can help stimulate digestive enzymes and improve digestion. This can be beneficial for the client to ease any potential digestive discomfort after the bowel obstruction.
Other choices are incorrect because:
A: Ginger tea is not typically used to regulate blood pressure.
C: While ginger can have some immune-boosting properties, the primary purpose in this scenario is related to digestion.
D: Ginger does have anti-inflammatory properties, but the client's request for ginger tea is more likely for digestive purposes.
A nurse is collecting data from a client who has narcolepsy. Which of the following manifestations should the nurse expect? (Select all that apply).
- A. Feeling extremely tired upon waking
- B. Sudden attacks of sleep
- C. Sleep-wake cycle hallucinations
- D. Sleep apnea
- E. Urge to move the legs when trying to sleep
Correct Answer: B, C
Rationale: The correct manifestations for narcolepsy are sudden attacks of sleep and sleep-wake cycle hallucinations. Narcolepsy is a neurological disorder characterized by excessive daytime sleepiness, sudden attacks of sleep (choice B), and disrupted REM sleep leading to sleep-wake cycle hallucinations (choice C). Choice A (feeling extremely tired upon waking) is more indicative of general fatigue rather than narcolepsy. Choice D (sleep apnea) is a separate sleep disorder characterized by pauses in breathing during sleep. Choice E (urge to move the legs when trying to sleep) is a symptom of restless leg syndrome, which is not typically associated with narcolepsy.
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg, his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?
- A. Schedule his next appointment for 1 year from now.
- B. Provide information about how to reduce risk factors of hypertension.
- C. Schedule an appointment for a prostate-specific antigen (PSA) test.
- D. Provide information for a weight loss plan that includes increasing physical activity.
Correct Answer: B
Rationale: The correct answer is B: Provide information about how to reduce risk factors of hypertension. The rationale is as follows: The patient is at risk for developing hypertension based on his age, ethnicity, and BP reading. Providing information on reducing risk factors such as maintaining a healthy diet, regular exercise, stress management, and avoiding tobacco and excess alcohol can help prevent the development of hypertension. This proactive approach aligns with preventive healthcare measures.
Choices A, C, and D are incorrect because scheduling the next appointment for 1 year from now does not address the potential risk of hypertension, a PSA test is unrelated to the patient's current presentation, and weight loss is not indicated as the patient's BMI is within the normal range.