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A patient has just been prescribed Minipress to control hypertension. The nurse should instruct the patient to be observant of the following:
- A. Dizziness and light headed sensations
- B. Weight gain
- C. Sensory changes in the lower extremities
- D. Fatigue
Correct Answer: A
Rationale: Hypotension may be result of over correction of a hypertensive condition.
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When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?
- A. polyandry
- B. soronal
- C. nonsororal
- D. sororate
Correct Answer: B
Rationale: The practice of polygamy refers to having multiple wives or husbands. When there are multiple wives who are sisters, the polygamy is designated as soronal. When the wives are not sisters it is nonsororal. Polyandry refers to multiple husbands and is rare. Some cultures practice a polygamy designated as sororate. Sororate polygamy specifies that a husband must marry his wife's sister if she dies. These marriages are successive rather than concurrent.
A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? What position should the nurse encourage the mother to assume?
- A. Prone
- B. Standing
- C. Supine
- D. Hands and knees
Correct Answer: D
Rationale: During back labor, when the back of the fetal head puts pressure on the woman's sacral promontory, the hands-and-knees position is encouraged. This position helps the fetus move away from the sacral promontory, reducing back pain and enhancing the internal-rotation mechanism of labor. A prone position would be difficult for the woman to assume and not helpful in relieving back discomfort. The supine position is risky due to supine hypotension, while standing may increase pressure, worsening backache.
To improve overall health, the nurse should place the highest priority on assisting a client to make lifestyle changes for which of the following habits?
- A. drinking a six-pack of beer each day
- B. eating an occasional chocolate bar
- C. exercising twice a week
- D. using relaxation exercises to deal with stress
Correct Answer: A
Rationale: To improve overall health, the nurse should prioritize assisting the client in making lifestyle changes that have the most significant impact on health. Drinking a six-pack of beer each day can have serious negative effects on health, including liver damage, increased risk of chronic diseases, and addiction. By addressing this habit first, the nurse can make a substantial positive difference in the client's health. Eating an occasional chocolate bar, exercising twice a week, and using relaxation exercises to deal with stress are beneficial habits, but they are not as detrimental to health as excessive alcohol consumption. Therefore, they are not the highest priority for immediate lifestyle changes to improve health.
While assessing a client’s skin, the nurse notes the presence of several large red-blue and purple areas on the client’s body that do not blanch when pressure is applied. The nurse documents this finding using which term?
- A. Psoriasis
- B. Anasarca
- C. Petechiae
- D. Ecchymosis
Correct Answer: D
Rationale: Ecchymosis refers to a large patch of capillary bleeding into the tissues, commonly known as a bruise. The color of such an area changes from red-blue or purple to green, yellow, and brown before the area disappears. Pressure on the area will not cause it to blanch. Psoriasis is characterized by scaly erythematous patches with silvery scales on top, usually found on specific areas like the scalp, elbows, knees, low back, and anogenital area. Anasarca is bilateral or generalized edema, indicating a central problem like congestive heart failure or kidney failure. Petechiae are tiny purple or red spots resulting from tiny hemorrhages within the dermal and subdermal areas. Therefore, in this case, the correct term to document the described finding is Ecchymosis.
A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if the mother performs which action?
- A. Uses a cotton-tipped swab to carefully clean inside the infant's nose
- B. Uncovers only the body part being washed
- C. Washes the diaper area first
- D. Washes the infant's chest first
Correct Answer: B
Rationale: When bathing a newborn, it is crucial to follow a specific sequence for thorough cleaning and safety. The correct sequence includes starting with the eyes and face, then moving to the external ear, areas behind the ears, neck, hands, arms, legs, and finally the diaper area. Keeping the infant warm is essential, so only the body part being washed should be uncovered. Using a cotton-tipped swab to clean inside the infant's nose is not recommended due to the risk of injury if the infant moves suddenly. Washing the diaper area first is incorrect as it should be done towards the end of the bath to prevent contamination. Washing the infant's chest first is also incorrect as it deviates from the recommended bathing sequence for a newborn.