Nokea
The best method of evaluating the amount of peripheral edema is:
- A. Weighing the client daily
- B. Measuring the extremity
- C. Measuring the intake and output
- D. Checking for pitting
Correct Answer: B
Rationale: Measuring the extremity provides a direct and quantifiable assessment of peripheral edema by tracking changes in circumference. Daily weighing can indicate fluid retention but is less specific, so answer A is incorrect. Intake and output monitoring does not directly measure edema, so answer C is incorrect. Checking for pitting assesses the presence of edema but not its amount, so answer D is incorrect.
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The nurse is collecting data from a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?
- A. decreased urine specific gravity
- B. blood pressure >=140/90 mm Hg
- C. urinalysis positive for ketones
- D. bradycardia
Correct Answer: C
Rationale: Hyperemesis gravidarum causes severe vomiting, leading to dehydration and starvation, resulting in ketosis. Positive ketones in urinalysis confirm this metabolic state.
A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client?
- A. Bronchial breath sounds at lung periphery
- B. Clear vesicular breath sounds at lung bases
- C. Diffuse bilateral crackles at lung bases
- D. Stridor in upper airways
Correct Answer: C
Rationale: Frothy, pink-tinged sputum and dyspnea indicate pulmonary edema, a complication of myocardial infarction. Diffuse bilateral crackles are heard due to fluid in the alveoli.
A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?
- A. Have an ophthalmologic examination every 6 months
- B. Take the medication on an empty stomach
- C. Take vitamin D and calcium supplements
- D. Wear a MedicAlert bracelet
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity. Regular ophthalmologic exams every 6 months are essential to monitor for early signs of retinal damage.
The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate?
- A. Assign the same nurses and caregivers to the child each day
- B. Avoid mentioning the loved one's death in the child's presence
- C. Explain the importance of being with the child to the parents
- D. Schedule time each day for age-appropriate play
Correct Answer: B
Rationale: Avoiding discussion of the grandparent's death may confuse the child or hinder grieving. Open, age-appropriate communication supports emotional processing.
The nurse has reinforced teaching for a client with newly diagnosed von Willebrand disease. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. I can use a humidifier to help prevent nosebleeds.
- B. I need to wear gloves while doing yard work.
- C. I should use a soft-bristled toothbrush and floss carefully.
- D. I will notify my health care provider if I soak a menstrual pad in an hour.
- E. I will take NAPROXEN to decrease pain and inflammation if I am injured.
Correct Answer: A,C,D
Rationale: Using a humidifier (A) prevents mucosal drying and nosebleeds. A soft-bristled toothbrush and careful flossing (C) minimize gum bleeding. Reporting heavy menstrual bleeding (D) is critical to manage bleeding risks in von Willebrand disease.