Nokea
At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states 'My blood pressure is usually much lower.' The nurse should tell the client to
- A. go get a blood pressure check within the next 48 to 72 hours
- B. check blood pressure again in 2 months
- C. see the health care provider immediately
- D. visit the health care provider within 1 week for a BP check
Correct Answer: A
Rationale: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is 'usually much lower,' a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
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A 9-month old is seen in the well child clinic. During the nursing assessment, the mother asks, 'Shouldn't he be making baby sounds by now? My friend's little boy is the same age and he is already saying dada.' The nurse reports the mother's concerns to the doctor for follow-up based on the knowledge that infants should be making rudimentary sounds by age:
- A. 1 month
- B. 2 months
- C. 4 months
- D. 8 months
Correct Answer: D
Rationale: Infants typically make cooing or babbling sounds by 6-8 months. Lack of sounds at 9 months warrants evaluation.
A father brings his 17-year-old son to a walk-in clinic. The client reports a sudden severe headache. He has a temperature of 104°F and a purple rash. What is the best action for the nurse at this time?
- A. Prepare for a throat culture
- B. Schedule him for an appointment later in the day
- C. Isolate and alert the physician immediately
- D. Obtain a urine specimen
Correct Answer: C
Rationale: Symptoms suggest meningococcal meningitis, a medical emergency requiring isolation and immediate physician notification.
The nurse is talking with a group of clients at a community health fair about colorectal cancer. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Clients over the age of 50 are at highest risk for colorectal cancer regardless of health status
- B. Consuming low amounts of red meat may reduce the risk for developing colorectal cancer
- C. Clients with inflammatory bowel disease are at higher risk for developing colorectal cancer
- D. Eating plenty of fruits and vegetables and maintaining a healthy weight may reduce the risk for developing colorectal cancer
- E. Clients with a parent or sibling who has had colorectal cancer should have screenings earlier and more often than other clients
Correct Answer: B,C,D,E
Rationale: Low red meat, high fruit/vegetable intake, and healthy weight reduce colorectal cancer risk. Inflammatory bowel disease and family history increase risk, necessitating earlier screenings. Risk rises after age 50, but health status matters, making the first statement inaccurate.
Which nursing action is essential in the care of an adult following a left side cardiac catheterization?
- A. Keep the client NPO for two hours.
- B. Ask the client about a shellfish allergy.
- C. Check pulses proximal to the insertion site.
- D. Check the insertion site for bleeding.
Correct Answer: D
Rationale: Checking the insertion site for bleeding is critical post-catheterization to detect hematoma or hemorrhage, ensuring patient safety.
When the nurse is caring for a client receiving a neuroleptic medication exhibiting torticollis and involuntary muscle movement, what is the priority nursing action?
- A. Have respiratory support equipment available
- B. Administer an antiemetic medication
- C. Monitor the client’s temperature closely
- D. Administer an antihistamine
Correct Answer: A
Rationale: Have respiratory support equipment available. These side effects could lead to respiratory failure, necessitating immediate respiratory support.