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An assistive personnel tells the nurse, 'I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?' The nurse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is:
- A. Low
- B. High
- C. Inaccurate
- D. Unaffected
Correct Answer: B
Rationale: Using a regular blood pressure cuff on a morbidly obese client will lead to a falsely high blood pressure reading. This occurs because the cuff is not appropriately sized for the client's arm circumference, resulting in increased pressure on the artery and an inaccurate high reading. Choice A is incorrect because the reading will be falsely high, not low. Choice C is incorrect as the reading will not be accurate with an incorrectly sized cuff. Choice D is incorrect because the reading will be affected by using the wrong cuff size.
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A client with hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?
- A. Fresh fruits
- B. Grilled chicken
- C. Whole grain bread
- D. Canned soup
Correct Answer: D
Rationale: The correct answer is D, canned soup. Canned soup is often high in sodium, which contradicts the low-sodium diet prescribed for hypertension. Fresh fruits (A) are generally low in sodium and are a healthy choice. Grilled chicken (B) is a lean protein option that is suitable for a low-sodium diet. Whole grain bread (C) is also a good choice as it is not typically high in sodium. Therefore, the LPN/LVN should recommend avoiding canned soup to adhere to the low-sodium dietary restrictions.
In planning care for a premature infant with respiratory distress syndrome, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to
- A. Stabilize alveolar surface tension
- B. Maintain alveolar surface tension
- C. Promote normal pulmonary blood flow
- D. Regulate intra-cardiac pressure
Correct Answer: B
Rationale: The correct answer is B: Maintain alveolar surface tension. Respiratory distress syndrome in premature infants is often caused by a deficiency in surfactant, a substance that helps maintain alveolar surface tension. Without adequate surfactant, the alveoli collapse, making it difficult for the infant to oxygenate effectively. Choices A, C, and D are incorrect because stabilizing alveolar surface tension is not the issue, promoting normal pulmonary blood flow and regulating intra-cardiac pressure are not directly related to the pathophysiology of respiratory distress syndrome in premature infants.
When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition?
- A. Fungi
- B. Friction
- C. Nail polish
- D. Nail polish remover
Correct Answer: A
Rationale: The nurse would most likely suspect fungi as the cause of thickened and separated toenails. Fungal infections can lead to changes in the nail structure, causing them to thicken and separate from the nail bed. Friction, nail polish, and nail polish remover are less likely to cause these specific nail changes. Friction typically leads to calluses or blisters, while nail polish and nail polish remover do not commonly result in thickened and separated toenails.
A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?
- A. Determine the client's sleep and activity patterns
- B. Obtain a prescription for the client to take when stressed
- C. Refer the client for a sleep study and neurological follow-up
- D. Teach coping strategies to use when feeling stressed
Correct Answer: A
Rationale: Assessing the client's sleep and activity patterns is crucial in understanding the factors contributing to the sleep difficulties and headaches. By evaluating these patterns, the nurse can identify triggers, stressors, and lifestyle habits that may be impacting the client's sleep quality and overall well-being. This assessment will guide the nurse in formulating an appropriate care plan tailored to the client's specific needs. Option B is not appropriate as it focuses solely on providing medication without addressing underlying issues. Option C is premature as a thorough assessment should precede any referrals for specialized studies. Option D, while important, should come after understanding the client's sleep patterns to provide more targeted coping strategies.
The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed.
- A. Administer nasal oxygen at a rate of 5 L/min
- B. Help the client to lie back down in the bed
- C. Quickly pivot the client to the chair and elevate the legs
- D. Check the client's blood pressure and pulse deficit
Correct Answer: D
Rationale: Checking the client's blood pressure and pulse deficit is essential before mobilizing a client out of bed, especially after surgery. This assessment helps ensure the client's stability and readiness for mobilization. Administering oxygen or pivoting the client without prior assessment could pose risks if the client is not medically stable. Helping the client lie back down without proper evaluation may delay necessary interventions if the client is indeed ready for mobilization.