Nokea
A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?
- A. Decreased heart rate
- B. Dyspnea
- C. Increased blood pressure
- D. Thready pulse
Correct Answer: D
Rationale: The correct answer is D: Thready pulse. Hypovolemia, or low blood volume, leads to decreased blood flow, resulting in a thready pulse due to decreased stroke volume. A: Decreased heart rate is not typically associated with hypovolemia as the body may try to compensate by increasing heart rate. B: Dyspnea may occur in hypovolemic shock, but it is not a specific manifestation of hypovolemia. C: Increased blood pressure is not a typical finding in hypovolemia, as the blood pressure tends to drop due to decreased fluid volume. Thus, D is the correct choice as it directly correlates with the pathophysiology of hypovolemia.
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A nurse is reinforcing teaching to a newly licensed nurse about caring for a client who is a member of the Seventh-Day Adventist church. The nurse should include in the teaching that which of the following foods are restricted with this religion?
- A. Leavened bread
- B. Eggs
- C. Milk
- D. Caffeinated coffee
Correct Answer: D
Rationale: The correct answer is D: Caffeinated coffee. Seventh-Day Adventists typically avoid caffeine due to health beliefs. Coffee contains caffeine, which is considered a stimulant and is restricted. Leavened bread (A) is not specifically restricted. Eggs (B) and milk (C) are generally accepted. In summary, the other choices are incorrect because they are not specifically restricted by the Seventh-Day Adventist church.
A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?
- A. Brachial
- B. Carotid
- C. Femoral
- D. Popliteal
Correct Answer: B
Rationale: The correct answer is B: Carotid. Checking the carotid pulse bilaterally simultaneously can lead to a temporary decrease in blood flow to the brain, potentially causing dizziness or fainting. It is important to assess one carotid pulse at a time to ensure adequate blood supply to the brain. Checking the brachial, femoral, and popliteal pulses bilaterally at the same time is safe as it does not pose a risk of compromising blood flow to critical organs.
A nurse is collecting data about a client's cranial nerves. Which of the following methods should the nurse use to identify a problem with cranial nerve II?
- A. Use a Snellen chart.
- B. Determine if the client's speech is hoarse.
- C. Present the client with mildly scented aromas.
- D. Ask the client to clench teeth.
Correct Answer: A
Rationale: The correct answer is A: Use a Snellen chart. Cranial nerve II, the optic nerve, is responsible for vision. By using a Snellen chart, the nurse can assess the client's visual acuity, which directly relates to the function of cranial nerve II. This method specifically targets the nerve in question and provides objective data on the client's vision.
Incorrect choices:
B: Determining if the client's speech is hoarse would assess cranial nerve X, the vagus nerve, responsible for speech and swallowing.
C: Presenting the client with scented aromas would assess cranial nerve I, the olfactory nerve, responsible for smell.
D: Asking the client to clench teeth would assess cranial nerve V, the trigeminal nerve, responsible for facial sensation and jaw movement.
A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
- A. Urine specific gravity 1.034
- B. Bounding pulse
- C. BP 146/94 mm Hg
- D. Distended neck veins
Correct Answer: A
Rationale: The correct answer is A: Urine specific gravity 1.034. Urine specific gravity measures the concentration of solutes in the urine, and a value of 1.034 indicates highly concentrated urine, which is a sign of dehydration. When the body is dehydrated, the kidneys conserve water, leading to concentrated urine.
Choice B, a bounding pulse, is a sign of fluid volume overload rather than dehydration. Choice C, high blood pressure, is not a direct indicator of dehydration. Choice D, distended neck veins, may be seen in conditions like heart failure but are not specific to dehydration. Overall, urine specific gravity is the most direct and reliable indicator of dehydration in this scenario.
A nurse is caring for four clients. Which of the following clients should the nurse expect to experience anticipatory grief?
- A. A client who has recently given up a child for adoption
- B. A client who experiences traumatic amputation of an extremity
- C. A client whose son committed suicide
- D. A client who has a new diagnosis of metastatic liver cancer
Correct Answer: D
Rationale: Anticipatory grief occurs when an individual knows a loss is imminent, as in terminal cancer.