Nokea
A nurse is collecting data from a client who is perimenopausal. Which of the following findings is the priority for the nurse to report to the provider?
- A. Difficulty sleeping
- B. Hot flashes
- C. Vaginal dryness
- D. Urinary frequency
Correct Answer: D
Rationale: Perimenopause involves hormonal shifts causing various symptoms, but priority follows clinical urgency. Urinary frequency stands out it could indicate a urinary tract infection, bladder dysfunction, or even a gynecologic issue like prolapse, all requiring prompt evaluation. Difficulty sleeping, hot flashes, and vaginal dryness are classic perimenopausal symptoms from estrogen decline, managed symptomatically unless severe. Frequency, however, suggests a potential complication beyond hormonal changes, possibly impacting renal or pelvic health. Using the ABCs or Maslow's hierarchy, urinary issues tie to elimination needs, outranking sleep or comfort concerns. Reporting this ensures timely diagnosis (e.g., urinalysis) and treatment, preventing progression to pyelonephritis or chronic conditions, making it the most pressing finding to escalate.
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NURSES’ NOTES
1000:
Client reports that over the past 2 months they have noticed multiple changes with their body. They have a decrease in activity tolerance, feel tired all the time, and have had difficulty remembering things. The client also states they bruise easily, are experiencing constipation, and they no longer tolerate the cold like they used to.
Client states they are concerned about exposure to seasonal viruses from other patrons.
Reports that they are currently experiencing a headache with a pain of 3 on a scale of 0 to 10.
Actions to Take
• Limit caffeine intake.
• Observe the need to administer sumatriptan.
• Withhold lithium.
Potential Condition
• Influenza
• Lithium toxicity
• Migraine
Parameters to Monitor
• Flashing lights
• Blurred vision
• Chest pain
A nurse in a provider's office is caring for a client who reports changes in their health over the past 2 months. What condition is the client most likely experiencing?
- A. Influenza
- B. Lithium toxicity
- C. Migraine
- D. Hypothyroidism
Correct Answer: D, A
Rationale: Symptoms like decreased activity tolerance, fatigue, memory issues, bruising, constipation, and cold intolerance over 2 months suggest hypothyroidism thyroid hormone deficiency slows metabolism, causing systemic effects. Influenza is acute, with fever and respiratory symptoms, not chronic fatigue or bruising. Lithium toxicity includes tremor or confusion, but not cold intolerance or constipation as primary signs. Migraine causes headaches (here, 3/10), but not multisystem changes like bruising or memory loss. Hypothyroidism fits the gradual onset and constellation fatigue from low energy, memory fog from cerebral hypoperfusion, and constipation from sluggish gut motility requiring thyroid function tests (e.g., TSH), making it the most likely condition.
A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?
- A. Ask the client to describe her feelings about the loss of the affected limb.
- B. Encourage the client to talk with another client who completed rehabilitation for amputation.
- C. Restrict visitors to family members until the client is able to wear a prosthesis.
- D. Suggest that family members bring clothing for the client from home.
- E. Instruct the client to ignore phantom pain sensations.
- F. Apply heat to the stump.
- G. Limit physical therapy.
Correct Answer: A,B,D
Rationale: Expressing feelings aids coping, peer support helps adjustment, and familiar clothing boosts morale; phantom pain should be addressed, not ignored.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects?
- A. Rhinitis
- B. Metallic taste
- C. Ringing in ears
- D. Agitation
- E. Weight gain
- F. Dry cough
- G. Blurred vision
Correct Answer: C
Rationale: Ringing in ears (tinnitus) is a sign of furosemide ototoxicity; rhinitis and metallic taste aren't typical.
A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?
- A. LDL
- B. INR
- C. BUN
- D. Hct
Correct Answer: B
Rationale: INR (International Normalized Ratio) measures clotting time and must be monitored with warfarin to ensure therapeutic anticoagulation and prevent bleeding or clotting complications in atrial fibrillation.
A nurse is preparing to perform a blood glucose test. After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?
- A. Cleanse the site with an antiseptic swab.
- B. Allow the site to dry.
- C. Pierce the puncture site quickly.
- D. Squeeze the site gently to obtain a blood droplet.
- E. Apply blood to the test strip.
Correct Answer: A,B,C,D,E
Rationale: Steps are: Cleanse (A), dry (B), pierce (C), squeeze (D), and apply (E), ensuring a clean and accurate glucose reading.