Nokea
A very tall, heavy-set man is admitted. The nurse is taking vital signs. Which statement is correct concerning taking the blood pressure?
- A. 10 mm should be added to each reading to compensate for the cuff size.
- B. 15 mm should be subtracted from the systolic reading, and 10 mm should be subtracted from the diastolic reading.
- C. An extra-large cuff is needed to obtain an accurate measurement.
- D. The client should lie down before the blood pressure is taken.
Correct Answer: C
Rationale: An extra-large cuff ensures accurate blood pressure measurement in large individuals; a standard cuff falsely elevates readings. Adjusting readings or lying down is unnecessary.
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The nurse is talking with a client with atrial fibrillation who has a new prescription for dabigatran. Which of the following statements by the client would require follow-up?
- A. I should use a soft-bristled toothbrush when brushing my teeth.'
- B. I will notify my health care provider if I notice blood in my urine or stool.'
- C. I should swallow the medication capsule whole with a full glass of water.'
- D. I will have blood specimens obtained periodically while taking the medication.'
Correct Answer: D
Rationale: Dabigatran does not require routine blood monitoring (D), unlike warfarin, so this statement requires follow-up. Soft toothbrush (A), reporting bleeding (B), and swallowing whole (C) are correct.
What would the nurse expect to see while assessing the growth of children during their school age years?
- A. Decreasing amounts of body fat and muscle mass
- B. Little change in body appearance from year to year
- C. Progressive height increase of 4 inches each year
- D. Yearly weight gain of about 5.5 pounds per year
Correct Answer: D
Rationale: School age children gain about 5.5 pounds each year and increase about 2 inches in height.
The nurse is caring for a client who has congestive heart failure. Which finding indicates that her condition is getting worse?
- A. An increase in urine output
- B. A decrease in blood pressure
- C. A decrease in heart rate
- D. Warm, moist skin
Correct Answer: B
Rationale: A decrease in blood pressure suggests worsening cardiac output in congestive heart failure, indicating decompensation.
A client is admitted with Parkinson's disease. The client has been taking Carbidopa/levodopa (Sinemet) for 1 year. Which clinical manifestation would be the most important to report?
- A. Dry mouth
- B. Spasmodic eye winking
- C. Dark urine
- D. Dizziness
Correct Answer: B
Rationale: Spasmodic eye winking could indicate a toxicity or overdose and should be reported to the physician. Other signs of toxicity include involuntary twitching of muscles, facial grimaces, and severe tongue protrusion. Answers A, C, and D are incorrect because they are side effects of the drug.
The client with COPD may lose weight despite having adequate caloric intake. When counseling the client in ways to maintain an optimal weight, the nurse should tell the client to:
- A. Continue the same caloric intake and decrease his activity level
- B. Increase his activity level to stimulate his appetite
- C. Increase the amount of complex carbohydrates and decrease the amount of fat intake
- D. Decrease the amount of complex carbohydrates while increasing calories, protein, fat, vitamins, and minerals
Correct Answer: D
Rationale: Clients with COPD often have increased metabolic demands and may lose weight. To maintain optimal weight, they should increase overall caloric intake, including protein, fat, vitamins, and minerals, while possibly decreasing complex carbohydrates to balance the diet. Answer A is incorrect as decreasing activity is not beneficial. Answer B may not be feasible due to respiratory limitations. Answer C does not address the need for increased calories and nutrients.