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How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?
- A. Poor left-sided motor control
- B. Paralysis or contractures on the right side
- C. Limited visual perception of the left fields
- D. Unawareness of the existence of her left side
Correct Answer: D
Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.
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While taking the history of an older adult client, which assessment finding alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance?
- A. "I am often cold and need to wear a sweater."?
- B. "I seem to urinate more when I drink coffee."?
- C. "In the summer, I feel thirsty more often."?
- D. "My rings seem to be tighter this week."?
Correct Answer: D
Rationale: The correct answer is 'My rings seem to be tighter this week.' This assessment finding indicates possible fluid retention, which can be a sign of fluid or electrolyte imbalance in an older adult. Choices A, B, and C do not specifically point towards fluid or electrolyte imbalance. Feeling cold, increased urination with coffee consumption, and feeling thirsty in the summer are not direct indicators of fluid or electrolyte imbalance in this context.
The healthcare provider is assessing a client before surgery. Which assessments contraindicate the client from having surgery as scheduled? (Select one that does not apply.)
- A. Potassium level of 2.8 mEq/L
- B. International normalized ratio (INR) of 4
- C. Prothrombin time (PT) of 30 seconds
- D. Positive pregnancy test
Correct Answer: C
Rationale: The correct answer is C: Prothrombin time (PT) of 30 seconds. A low potassium level (choice A) and an elevated INR (choice B) indicate potential bleeding risks during surgery. A positive pregnancy test (choice D) in a female client can lead to complications during surgery. However, a Prothrombin time of 30 seconds is within the normal range and does not contraindicate the client from having surgery as scheduled.
When obtaining a client's vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse's best intervention?
- A. Call the healthcare provider and report the finding.
- B. Reassess the client's blood pressure at the next follow-up appointment.
- C. Administer an additional antihypertensive medication to the client.
- D. Teach the client lifestyle modifications to decrease blood pressure.
Correct Answer: D
Rationale: The correct answer is to teach the client lifestyle modifications to decrease blood pressure. A blood pressure reading of 134/88 mm Hg falls within the prehypertension range. The initial approach to managing prehypertension involves lifestyle modifications such as dietary changes, exercise, and stress reduction techniques. Calling the healthcare provider without attempting non-pharmacological interventions first is premature. Reassessing blood pressure at the next follow-up appointment may delay necessary interventions. Administering additional antihypertensive medication is not indicated at this stage as lifestyle modifications are the first line of treatment for prehypertension.
The healthcare professional is assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?
- A. Absence of pedal edema in the lower legs.
- B. Absence of complaints of sexual dysfunction.
- C. No indication of renal impairment.
- D. Blood pressure reading of 148/94 mm Hg.
Correct Answer: C
Rationale: The correct answer is 'No indication of renal impairment.' Effective hypertension management aims to prevent complications such as renal impairment. Checking for signs of kidney issues, like abnormal renal function tests, is crucial in monitoring the client's condition. Choices A, B, and D are not specific indicators of effective hypertension management. Pedal edema, sexual dysfunction, and a single blood pressure reading are important but do not solely determine the effectiveness of managing hypertension.
The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, "Breathing in using this thing (incentive spirometer) is a ridiculous waste of time."? What is the nurse's best response?
- A. "The spirometer will help you cough effectively."?
- B. "The spirometer will help your lungs expand."?
- C. "The spirometer will help prevent blood clots."?
- D. "The spirometer will improve blood flow in your lungs."?
Correct Answer: B
Rationale: The correct answer is, '"The spirometer will help your lungs expand."?' Incentive spirometry is used postoperatively to help prevent atelectasis by expanding the lungs and improving lung function. Choice A is incorrect because the primary purpose of the spirometer is not to help cough effectively. Choice C is incorrect because while deep breathing with the spirometer can indirectly help prevent blood clots by improving lung function, its primary purpose is not to prevent blood clots directly. Choice D is incorrect because although using the spirometer can improve ventilation and oxygenation, its main purpose is not to improve blood flow in the lungs.