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After stabilization of Addison's disease, the nurse teaches the client about stress management. The nurse should instruct the client to:
- A. Remove all sources of stress from daily life.
- B. Use relaxation techniques such as music.
- C. Take antianxiety drugs daily.
- D. Avoid discussing stressful experiences.
Correct Answer: B
Rationale: Relaxation techniques like music help manage stress, reducing glucocorticoid demands in Addison's disease.
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Which of the following should the nurse provide as part of the information to prepare the client for tonometry?
- A. Oral pain medication will be given before the procedure.
- B. It is a painless procedure with no adverse effects.
- C. Blurred or double vision may occur after the procedure.
- D. Medication will be given to dilate the pupils before the procedure.
Correct Answer: B
Rationale: Tonometry measures intraocular pressure and is typically painless with no adverse effects, requiring no pupil dilation or pain medication.
Which position would most help to decrease a client's discomfort when the client's spouse injects vitamin B12 using the ventrogluteal site?
- A. Lying on the side with legs extended.
- B. Lying on the abdomen with toes pointed inward.
- C. Leaning over the edge of a low table with hips flexed.
- D. Standing upright with the feet one shoulder-width apart.
Correct Answer: B
Rationale: The ventrogluteal site is best accessed when the client lies on their abdomen with toes pointed inward, as this position relaxes the gluteal muscles and minimizes discomfort during injection. The other positions do not optimally relax the muscle or provide access to the ventrogluteal site.
The client has had hypertension for 20 years. The nurse should assess the client for?
- A. Renal insufficiency and failure.
- B. Valvular heart disease.
- C. Endocarditis.
- D. Peptic ulcer disease.
Correct Answer: A
Rationale: Long-standing hypertension damages kidneys, leading to renal insufficiency or failure, a common complication requiring assessment.
A common abnormal laboratory result associated with the development of peripheral vascular disease (PVD) is:
- A. High serum calcium level
- B. High serum lipid levels
- C. Low serum lipid levels
- D. Low serum calcium level
Correct Answer: B
Rationale: High serum lipid levels, particularly elevated low-density lipoprotein (LDL) cholesterol, are a major risk factor for atherosclerosis, which underlies PVD. Lipid accumulation in arterial walls leads to plaque formation, narrowing vessels and reducing blood flow. Calcium levels are not directly associated with PVD, and low lipid levels are not a risk factor.
The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent:
- A. Cardiac arrhythmias.
- B. Liver failure.
- C. Renal failure.
- D. Hemorrhage.
Correct Answer: D
Rationale: AML causes pancytopenia, including thrombocytopenia, increasing the risk of hemorrhage. Preventing bleeding is a primary nursing goal through measures like avoiding invasive procedures and monitoring for bleeding signs. Arrhythmias, liver, and renal failure are less immediate concerns.