Nokea
A nurse is teaching a patient with chronic hypertension about lifestyle changes. Which of the following is the most appropriate teaching for this patient?
- A. "You should increase your sodium intake to maintain good blood pressure."
- B. "It is important to increase physical activity and reduce stress."
- C. "Take your medications only when your blood pressure increases."
- D. "You should monitor your blood pressure every week."
Correct Answer: B
Rationale: The correct answer is B because increasing physical activity and reducing stress are important lifestyle changes for managing chronic hypertension. Exercise helps lower blood pressure and stress reduction techniques can help control hypertension. Option A is incorrect as reducing sodium intake, not increasing it, is recommended. Option C is incorrect as medications for hypertension should be taken as prescribed, not only when blood pressure increases. Option D is incorrect as monitoring blood pressure should be done regularly, but not necessarily every week.
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What should be done for a client who is post-op and develops a fever within the first 48 hours?
- A. Administer antipyretics
- B. Monitor for signs of infection
- C. Administer fluids
- D. Perform an abdominal assessment
Correct Answer: B
Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.
A nurse is caring for a patient who is receiving chemotherapy. The nurse should monitor for signs of which of the following complications?
- A. Anemia.
- B. Hyperkalemia.
- C. Neutropenia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Neutropenia. Chemotherapy can suppress bone marrow function, leading to a decrease in neutrophils (a type of white blood cell), causing neutropenia. This increases the risk of infection. Monitoring for signs of infection is crucial in patients receiving chemotherapy to prevent serious complications. Anemia (A) is a common side effect of chemotherapy but is not directly related to infection risk. Hyperkalemia (B) and hypocalcemia (D) are less likely to be immediate complications of chemotherapy compared to neutropenia.
What term describes excessive stretching of a ligament, as seen in a client with a pulled ligament?
- A. sprain
- B. strain
- C. subluxation
- D. distortion
Correct Answer: B
Rationale: The correct answer is B: strain. A strain refers to excessive stretching or tearing of a muscle or tendon, not a ligament. A sprain (choice A) is the correct term for excessive stretching of a ligament. Subluxation (choice C) refers to partial dislocation of a joint, not a ligament injury. Distortion (choice D) is a general term that does not specifically describe ligament stretching. Therefore, the correct term for excessive stretching of a ligament is a sprain, making choice A the correct answer.
What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
- A. Place the client on their back and administer pain medication
- B. Place the client on their side and administer antibiotics
- C. Administer IV fluids and antibiotics
- D. Perform a lumbar puncture
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.
What should be the first intervention for a client suspected of having a stroke?
- A. Monitor neurological status
- B. Perform a CT scan
- C. Administer fibrinolytics
- D. Perform MRI
Correct Answer: B
Rationale: The correct first intervention for a client suspected of having a stroke is to perform a CT scan (Choice B). This is because a CT scan can quickly identify the type of stroke (ischemic or hemorrhagic) and guide treatment decisions. Monitoring neurological status (Choice A) can be important but does not provide a definitive diagnosis. Administering fibrinolytics (Choice C) should only be done after confirming the type of stroke to avoid complications. Performing an MRI (Choice D) is more time-consuming and may not be feasible in the acute setting where quick intervention is crucial. Therefore, a CT scan is the most appropriate initial intervention for a suspected stroke.