Nokea
A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
- A. Intake 2,500 mL, output 500 mL
- B. Intake 2,400 mL, output 2,500 mL
- C. Intake 1,200 mL, output 700 mL
- D. Intake 800 mL, output 2,100 mL
Correct Answer: B
Rationale: A fluid intake close to output indicates balance. Excess output or retention suggests dehydration or overload.
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A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data?
- A. Blood pressure
- B. Cyanosis
- C. Nausea
- D. Petechiae
Correct Answer: C
Rationale: Subjective data are information reported by the client, such as symptoms or feelings. Nausea is subjective because the client experiences and reports it. Blood pressure, cyanosis, and petechiae are objective data that can be measured or observed directly by the nurse. Blood pressure is a vital sign, cyanosis is a physical finding, and petechiae are skin manifestations. Therefore, they are not subjective data. By understanding the distinction between subjective and objective data, the nurse can accurately assess and document the client's health status.
A nurse receives a client's laboratory results and notes a potassium level of 3.1 mEq/L. When reviewing the client's medication administration record, which of the following types of medication should the nurse identify as a contributing factor to the client's electrolyte imbalance?
- A. Corticosteroids
- B. NSAIDs
- C. ACE inhibitors
- D. SSRIs
Correct Answer: A
Rationale: Corticosteroids can cause potassium loss through increased renal excretion, leading to hypokalemia.
A nurse is caring for a client who wants information about a complementary or alternative healing modality to help her reduce stress. The nurse should suggest which of the following modalities in which the client can practice poses and meditation to achieve wellness?
- A. Reiki
- B. Aromatherapy
- C. Acupuncture
- D. Yoga
Correct Answer: D
Rationale: Yoga combines physical postures, breathing exercises, and meditation to reduce stress and promote well-being.
A nurse is reinforcing teaching with a 40-year-old female client about preventive health screenings. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my skin checked every 5 years for cancer.
- B. I will need to have a mammogram every year now.
- C. I should have my first colonoscopy when I turn 65.
- D. I will be checked for uterine cancer every 2 years.
Correct Answer: B
Rationale: The correct answer is B: "I will need to have a mammogram every year now." Mammograms are recommended for women starting at age 40 to screen for breast cancer. Annual mammograms help detect any abnormalities early, improving the chances of successful treatment. Choice A is incorrect as skin checks should be done annually. Choice C is incorrect as the first colonoscopy is usually recommended at age 50. Choice D is incorrect as there is no standard screening for uterine cancer every 2 years.
A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct findings for a client with Bell's palsy are muscle distortion, pain behind the ear, and impaired taste. Muscle distortion occurs due to facial nerve paralysis, leading to drooping or weakness on one side of the face. Pain behind the ear can result from inflammation of the facial nerve. Impaired taste can occur due to dysfunction of the taste buds innervated by the facial nerve. Hearing loss (C) is not typically associated with Bell's palsy. Facial twitching (D) may occur in other conditions like hemifacial spasm but not a defining feature of Bell's palsy.