Nokea
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
- A. These discomforts should decrease with time.
- B. You should avoid intercourse to prevent injury to your vagina.
- C. Women your age experience thickening of the vaginal tissue.
- D. Your symptoms are likely due to decreasing estrogen levels.
Correct Answer: D
Rationale: The correct answer is D: Your symptoms are likely due to decreasing estrogen levels. As women age, estrogen levels decrease leading to vaginal dryness and itching. This is a common symptom of menopause. By acknowledging the client's symptoms are likely due to decreasing estrogen levels, the nurse shows understanding and can provide appropriate education and treatment options. Choice A is incorrect as symptoms may persist without intervention. Choice B is incorrect as it does not address the underlying cause. Choice C is incorrect as it is not a typical experience for women of that age.
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A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
- A. Blood glucose of 110 mg/dL
- B. Decrease in blood pressure
- C. Increase in urinary output
- D. Respiratory rate of 16/min
Correct Answer: B
Rationale: The correct answer is B: Decrease in blood pressure. Telmisartan is an angiotensin II receptor blocker used to treat hypertension. A decrease in blood pressure indicates that the medication is effective in controlling hypertension. This is the desired outcome of telmisartan therapy as it helps reduce the risk of cardiovascular events. Choices A, C, and D are not directly related to the effectiveness of telmisartan. Blood glucose level and urinary output are not typically influenced by telmisartan, and respiratory rate is not a primary indicator of its effectiveness. Therefore, the most appropriate indicator of telmisartan's effectiveness in this scenario is a decrease in blood pressure.
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
- A. Loss of peripheral vision
- B. Inability to smell
- C. Deviation of the tongue from midline
- D. Disequilibrium with movement
Correct Answer: D
Rationale: The correct answer is D: Disequilibrium with movement. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for both hearing and balance. Impaired function of this nerve can result in symptoms such as dizziness, vertigo, and disequilibrium with movement. This is because the vestibular branch of the nerve is crucial for maintaining balance and spatial orientation.
Choice A, loss of peripheral vision, is not related to cranial nerve VIII but rather to cranial nerve II, the optic nerve. Choice B, inability to smell, is associated with cranial nerve I, the olfactory nerve. Choice C, deviation of the tongue from midline, is a sign of dysfunction of cranial nerve XII, the hypoglossal nerve.
In summary, the correct answer is D because impaired function of the vestibulocochlear nerve (cranial nerve VIII) would result in disequilibrium with movement, while the other choices are related to different cranial
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
- A. Collect a urine sample
- B. Check the clients' vital signs
- C. Stop the infusion
- D. Administer oxygen to the client
Correct Answer: C
Rationale: The correct answer is C: Stop the infusion. The client is showing signs of a transfusion reaction, which can be serious. Stopping the infusion is the first priority to prevent further complications. Vital signs should be checked next to assess the client's condition. Collecting a urine sample is not a priority in this situation. Administering oxygen may be necessary depending on the client's condition, but stopping the infusion takes precedence.
A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- A. I plan to take this medication for 1 week.
- B. I should take an antacid with each dose of this medication.
- C. This medication may cause my blood pressure to increase.
- D. I will have my liver function tested while I am taking this medication.
Correct Answer: D
Rationale: The correct answer is D: "I will have my liver function tested while I am taking this medication." This is the correct answer because isoniazid (INH) is known to potentially cause liver toxicity. Monitoring liver function tests is crucial to detect any signs of liver damage early. Choice A is incorrect as INH treatment for tuberculosis typically lasts 6-9 months, not just 1 week. Choice B is incorrect because antacids can decrease the absorption of INH. Choice C is incorrect as INH does not typically cause an increase in blood pressure.
A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
- A. Oily skin
- B. Alopecia
- C. Increased salivation
- D. Diplopia
Correct Answer: B
Rationale: The correct answer is B: Alopecia. Alopecia, or hair loss, is a common manifestation of malnutrition due to inadequate intake of essential nutrients. Malnutrition can lead to hair thinning and loss. Oily skin (A) is more commonly associated with excess intake of fats. Increased salivation (C) is not a typical manifestation of malnutrition. Diplopia (D), or double vision, is not directly related to malnutrition.