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A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication?
- A. The client reports dizziness when ambulating to the bathroom
- B. The client reports having trouble sleeping the previous night
- C. The client ate 60% of their breakfast
- D. The client has a urine output of 400 mL for the past 8 hr
Correct Answer: A
Rationale: The correct answer is A. Dizziness when ambulating can be a sign of orthostatic hypotension, a potential side effect of antihypertensive medication. The nurse should further assess for signs of hypotension before administering the medication. Choices B, C, and D are less relevant to antihypertensive medication administration. Reporting trouble sleeping, eating 60% of breakfast, and having a urine output of 400 mL are not direct contraindications for administering antihypertensive medication.
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A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Increased blood pressure
- B. Increased hematocrit
- C. Increased respiratory rate
- D. Increased heart rate
- E. Increased temperature
Correct Answer: A,C,D
Rationale: The correct answer is A, C, and D. Fluid overload leads to increased blood pressure due to the increased volume of fluid in the vascular system. Increased respiratory rate occurs as the body tries to compensate for the excess fluid by increasing oxygen intake. Increased heart rate is a response to the increased workload on the heart to pump the excess fluid. Increased hematocrit and temperature are not typically associated with fluid overload. Hematocrit may actually be decreased due to hemodilution, and temperature is usually unaffected unless there is an underlying infection.
A nurse is teaching a class about expected physiological changes in older adult clients. Which of the following changes should the nurse include?
- A. Increase in startle reflex
- B. Increase in muscle mass
- C. Decrease in body fat
- D. Decrease in systolic blood pressure
Correct Answer: A
Rationale: The correct answer is A: Increase in startle reflex. As individuals age, their neurological system undergoes changes leading to increased sensitivity and exaggerated responses, including an increase in the startle reflex. This change is attributed to alterations in neurotransmitter levels and sensory processing.
Incorrect Answers:
B: Increase in muscle mass - Muscle mass typically decreases with age due to hormonal changes and decreased physical activity.
C: Decrease in body fat - Older adults tend to experience an increase in body fat and a decrease in muscle mass, contributing to changes in body composition.
D: Decrease in systolic blood pressure - While blood pressure tends to increase with age due to changes in blood vessel elasticity and hormonal changes, a decrease in systolic blood pressure is not a common expected physiological change in older adults.
A nurse is caring for a client who has a terminal diagnosis and states, 'I am ready to update my will.' The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief?
- A. Denial
- B. Acceptance
- C. Anger
- D. Bargaining
Correct Answer: B
Rationale: The correct answer is B: Acceptance. The client expressing readiness to update their will indicates acceptance, one of the stages of grief according to Kubler-Ross. This stage involves coming to terms with the reality of the situation and making necessary preparations. Denial (choice A) involves refusing to accept the diagnosis, anger (choice C) involves feelings of frustration and unfairness, and bargaining (choice D) involves seeking ways to avoid the inevitable. In this scenario, the client's statement aligns with the acceptance stage, as they are taking practical steps to prepare for the future.
A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.8
Rationale: The correct answer is 0.8 mL. To determine this, divide the desired dose (30 mg) by the concentration (40 mg/mL) to get 0.75. Since we need to round to the nearest tenth, 0.75 rounds up to 0.8 mL. The other choices are incorrect because: A: 0.7 mL, B: 0.9 mL, C: 0.6 mL, D: 1.0 mL, E: 0.5 mL, F: 1.2 mL, G: 0.3 mL. These choices do not accurately reflect the calculated dose based on the given information.
A nurse is caring for a client whose partner died 3 years ago and reports that they are still unable to accept the loss. The nurse should identify that the client has manifestations of which of the following types of grief?
- A. Uncomplicated grief
- B. Prolonged grief
- C. Anticipatory grief
- D. Disenfranchised grief
Correct Answer: B
Rationale: The correct answer is B: Prolonged grief. This is because the client is still struggling to accept the loss after 3 years, which is indicative of prolonged grief. Uncomplicated grief (Choice A) typically resolves within a reasonable timeframe. Anticipatory grief (Choice C) occurs before the actual loss. Disenfranchised grief (Choice D) is when the individual's grief is not openly acknowledged or socially supported. In this scenario, the client's grief extends beyond the normal grieving process, indicating prolonged grief.