Nokea
A nurse is caring for an older adult client who has confusion and weakness. The client has a Hct of 53%, a BUN of 25 mg/dL, and a urine specific gravity of 1.232. Which of the following actions should the nurse contribute to the client's plan of care?
- A. Restrict the client's fluid intake.
- B. Monitor the client's intake and output.
- C. Weigh the client daily.
- D. Instruct the client to sit on the side of the bed for a few minutes before standing.
- E. Check the client's orientation to person, place, and time regularly.
Correct Answer: B,C,E
Rationale: The lab values suggest dehydration, so monitoring fluid balance and orientation is essential.
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A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?
- A. Inability to regulate body temperature
- B. Bradycardia
- C. Visual disturbances
- D. Inability to perceive sound
Correct Answer: A
Rationale: The correct answer is A: Inability to regulate body temperature. The hypothalamus plays a crucial role in regulating body temperature. Surgery near this area can disrupt its function, leading to potential problems in thermoregulation. The nurse should monitor the client for signs of hyperthermia or hypothermia. Bradycardia (choice B) is more related to dysfunction in the cardiovascular system, not typically affected by surgery near the hypothalamus. Visual disturbances (choice C) and inability to perceive sound (choice D) are more associated with areas of the brain responsible for processing sensory information, not specifically linked to the hypothalamus.
When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?
- A. Wrapping the cuff too loosely around the client's arm
- B. Positioning the client's arm above heart level
- C. Measuring blood pressure right after the client's mealtime
- D. Deflating the cuff too slowly
Correct Answer: B
Rationale: The correct answer is B: Positioning the client's arm above heart level. When the client's arm is positioned above heart level, it can lead to an artificially low blood pressure reading due to gravitational effects. This position can cause blood to pool in the arm, reducing the pressure in the arteries and resulting in an inaccurate measurement. This error is known as hydrostatic pressure error. Wrapping the cuff too loosely (choice A) can lead to an inaccurate reading due to inadequate compression of the artery. Measuring blood pressure right after a meal (choice C) can also affect the reading due to the body's response to food intake. Deflating the cuff too slowly (choice D) can result in a falsely elevated diastolic reading.
A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and encourages the client to share their reason for seeking medical care, providing valuable information for the nurse to assess the client's health needs. Choice B is too broad and may overwhelm the client. Choice C puts the onus on the client to initiate the discussion. Choice D focuses on emotions rather than the primary reason for the hospitalization.
A nurse is collecting data from a client who is experiencing stress. Which of the following findings should indicate to the nurse ineffective coping?
- A. The client takes a 20-min nap each afternoon.
- B. The client has gained 4.5 kg (10 lb) in the past month.
- C. The client is taking a poetry class.
- D. The client takes a walk for 1 hr each day.
Correct Answer: B
Rationale: Sudden weight gain can be a sign of ineffective coping, such as emotional eating.
A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?
- A. Restrain the client as soon as seizure activity begins.
- B. Keep the lights on when the client is sleeping.
- C. Keep the client's bed in the lowest position.
- D. Have a padded tongue depressor available at the bedside.
Correct Answer: C
Rationale: The correct answer is C: Keep the client's bed in the lowest position. This is important for client safety during a seizure as it reduces the risk of injury from falling out of bed. Keeping the bed low ensures a shorter fall distance and minimizes the impact. Restraint (choice A) is not recommended as it can lead to further injury during a seizure. Keeping lights on (choice B) can trigger seizures in some individuals. Having a padded tongue depressor available (choice D) is not relevant to seizure precautions.