Nokea
The client is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate notification of the physician?
- A. Blood pressure of 140/90
- B. 2+ proteinuria
- C. Headache and visual disturbances
- D. Edema of the hands
Correct Answer: C
Rationale: Headache and visual disturbances in gestational hypertension suggest severe preeclampsia or impending eclampsia requiring immediate physician notification. BP of 140/90 proteinuria and edema are concerning but less urgent unless severe.
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A client is admitted with symptoms of vertigo and syncope.
- A. Memory loss and disorientation
- B. Numbness in the face, mouth, and tongue
- C. Radial pulse differences over 10 bpm
- D. Frontal headache with associated nausea or emesis
Correct Answer: C
Rationale: Left subclavian artery obstruction can cause subclavian steal syndrome, leading to vertigo, syncope, and radial pulse differences (>10 bpm) due to blood flow reversal. Memory loss (A), numbness (B), and headache (D) are unrelated.
A client has viral encephalitis and has been prescribed IV acyclovir (Zovirax). What nursing interventions should be used when administering the drug?
- A. Administer at a slow rate.
- B. Assure the client is well hydrated before giving the drug.
- C. Observe for neurotoxicity.
- D. Check the apical heart rate prior to administration.
- E. Infuse cautiously in clients with renal insufficiency.
Correct Answer: A, B, C, E
Rationale: Acyclovir requires slow infusion (A) to prevent phlebitis, adequate hydration (B) to reduce nephrotoxicity, monitoring for neurotoxicity (C), and caution in renal insufficiency (E). Heart rate (D) is unrelated.
A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of:
- A. Humulin N
- B. Humulin R
- C. Humulin U
- D. Humulin L
Correct Answer: B
Rationale: Regular insulin is rapid acting and indicated in an emergency situation.
A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
- A. Increase cardiac output
- B. Indicate cardiac tamponade
- C. Decrease cardiac output
- D. Indicate graft rejection
Correct Answer: C
Rationale: Fever post-CABG increases metabolic demand, potentially decreasing cardiac output in a compromised heart, requiring immediate attention. Tamponade and rejection have other signs.
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
- A. Denial
- B. Displacement
- C. Regression
- D. Projection
Correct Answer: C
Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.