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An older adult client visits the community health clinic and reports the onset of pain, redness, and swelling of the right eye. Which question is most important for the clinic nurse to ask the client?
- A. do you have any discharge from the eye
- B. have you started any new prescriptions
- C. are all of your immunizations current
- D. how often do you wash your hands
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum osmolality of 280 mOsm/kg.
- C. Weight gain of 2 pounds in 24 hours.
- D. Serum sodium of 130 mEq/L.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?
- A. Oxygen saturation of 88%.
- B. Use of accessory muscles for breathing.
- C. Respiratory rate of 26 breaths per minute.
- D. Barrel-shaped chest.
Correct Answer: C
Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.
A client with hyperthyroidism is receiving radioactive iodine therapy. Which statement by the client indicates a need for further teaching?
- A. I should avoid close contact with pregnant women and children for a few days.
- B. I may experience dry mouth and taste changes for a few days.
- C. I may experience some neck swelling.
- D. I may experience some neck swelling.
Correct Answer: D
Rationale: The correct answer is 'D.' The client stating 'I may experience some neck swelling' does not indicate a need for further teaching since neck swelling is an expected side effect of radioactive iodine therapy. Choices A and B are correct statements as the client should avoid close contact with pregnant women and children for a few days due to radiation exposure, and dry mouth and taste changes are common side effects. Choice C is redundant with choice D, making D the correct answer.
The communi ty health nurse is planning a series of educational courses about the heal thcare system and meeti ng heal thcare needs for t he community center. Which adjunct issue shoul d the nurs e address for a group of ol der adul ts.
- A. peer concerns
- B. adul t daycare
- C. reti rement i ssues
- D. vocati onal concerns -
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client with a nasogastric tube to continuous suction. Which electrolyte imbalance should the nurse monitor for?
- A. Hypercalcemia.
- B. Hypokalemia.
- C. Hyponatremia.
- D. Hypomagnesemia.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.