Nokea
A prenatal client is being evaluated for possible gestational diabetes. Which data identified and documented after the client's initial nursing assessment would support that diagnosis?
- A. 22 years old
- B. A gravida 4, para 0, aborta 3
- C. 5^{\prime} 6^{\prime \prime tall, weighs 130 pounds
- D. Stated, 'I get really tired after working all day'
Correct Answer: B
Rationale: A history of unexplained stillbirths or miscarriages puts the client at high risk for gestational diabetes. Fatigue is a normal occurrence during pregnancy. The client's height (5'6†tall) and weight (130 pounds) do not meet the criteria of 20% over ideal weight. Therefore, the client is not obese, a possible factor related to gestational diabetes. To be at high risk for gestational diabetes, the maternal age should be greater than 25 years.
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A client who is being treated for acute heart failure has the following vital signs: blood pressure (BP), 85/50 mm Hg; pulse, 96 beats per minute; respirations, 26 breaths per minute. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client's vital signs should the nurse expect?
- A. BP 85/50 mm Hg, pulse 60 beats per minute, respirations 26 breaths per minute
- B. BP 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute
- C. BP 130/70 mm Hg, pulse 104 beats per minute, respirations 20 breaths per minute
- D. BP 110/40 mm Hg, pulse 110 beats per minute, respirations 20 breaths per minute
Correct Answer: B
Rationale: The main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with heart failure. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well. The remaining choices do not reflect the physiological changes attributed to this medication.
The nurse creates a discharge plan for a client who had an abdominal hysterectomy. Which activity instructions should the nurse include in the plan? Select all that apply.
- A. Avoid heavy lifting.
- B. Sit as much as possible.
- C. Take baths rather than showers.
- D. Limit stair climbing to five times a day.
- E. Gradually increase walking as exercise but stop before becoming fatigued.
- F. Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks.
Correct Answer: A,D,E,F
Rationale: After abdominal hysterectomy, the client should avoid lifting anything that is heavy and limit stair climbing to five times a day. The client should walk indoors for the first week and then gradually increase walking as exercise, but stop before becoming fatigued. The client should avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks. The client is also told to avoid the sitting position for extended periods, to take showers rather than tub baths, avoid crossing the legs at the knees, and avoid driving for at least 4 weeks or until the surgeon has given permission to do so.
After undergoing a thyroidectomy, a client is monitored for signs of damage to the parathyroid glands postoperatively. The nurse would determine which finding suggests damage to the parathyroid glands?
- A. Fever
- B. Neck pain
- C. Hoarseness
- D. Tingling around the mouth
Correct Answer: D
Rationale: The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when parathyroid hormone (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers and muscular twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek's and Trousseau's signs. Fever may be expected in the immediate postoperative period but is not an indication of damage to the parathyroid glands. However, if a fever persists the primary health care provider is notified. Neck pain and hoarseness are expected findings postoperatively.
The nurse admits a client who is in sickle cell crisis. The nurse should prepare for which intervention as a priority in the management of the client?
- A. Pain management with an opioid
- B. Intravenous fluid therapy
- C. Oxygen administration
- D. Blood transfusion
Correct Answer: C
Rationale: The priority nursing intervention for a client in sickle cell crisis is to administer supplemental oxygen because the client is hypoxemic, and as a result, the red blood cells change to the sickle shape. In addition, oxygen is the priority because airway and breathing are more important than circulatory needs. The nurse also plans for fluid therapy to promote hydration and reverse the agglutination of sickled cells, opioid analgesics for relief from severe pain, and blood transfusions (rather than iron administration) to increase the blood's oxygen-carrying capacity.
A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On assessment, which manifestation related to the client's menstrual cycle should the nurse expect the client to report?
- A. Amenorrhea
- B. Menorrhagia
- C. Metrorrhagia
- D. Dysmenorrhea
Correct Answer: A
Rationale: Amenorrhea or a decreased menstrual flow is common in the client with Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves' disease.