Nokea
The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?
- A. I have stomach pain every time I eat a big, heavy meal.'
- B. I don’t have any abdominal pain or any type of problems.'
- C. I have periodic episodes of constipation and then diarrhea.'
- D. I belch a lot, especially when I lie down after eating.'
Correct Answer: B
Rationale: Small AAAs are often asymptomatic (B). Postprandial pain (A), bowel changes (C), and belching (D) suggest GI issues, not AAA.
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Which medication side effect should the nurse monitor for in a client taking an ACE inhibitor?
- A. Dry cough
- B. Weight gain
- C. Increased thirst
- D. Muscle cramps
Correct Answer: A
Rationale: ACE inhibitors commonly cause a dry cough due to increased bradykinin levels.
Which assessment finding indicates a worsening condition in a client with pericarditis?
- A. Muffled heart sounds
- B. Heart rate of 80 beats per minute
- C. Blood pressure of 120/80 mmHg
- D. Mild chest discomfort
Correct Answer: A
Rationale: Muffled heart sounds suggest pericardial effusion or cardiac tamponade, indicating worsening pericarditis.
The nurse is assessing a client with hypertension. Which finding requires immediate action?
- A. Blood pressure of 160/100 mmHg
- B. Headache rated 4/10
- C. Blurred vision and confusion
- D. Pulse rate of 88 beats per minute
Correct Answer: C
Rationale: Blurred vision and confusion indicate a hypertensive crisis, which can lead to organ damage and requires immediate intervention.
Which intervention should the nurse prioritize for a client with ventricular tachycardia?
- A. Administer lidocaine as prescribed.
- B. Check blood pressure.
- C. Encourage deep breathing.
- D. Apply oxygen at 2 L/min.
Correct Answer: A
Rationale: Lidocaine is used to suppress ventricular tachycardia, a life-threatening arrhythmia.
As the nurse provides discharge instructions to the client with varicose veins, which activity should the nurse suggest the client avoid?
- A. Walking in athletic shoes.
- B. Jogging a mile a day.
- C. Sitting with crossed knees.
- D. Wearing wool socks.
Correct Answer: C
Rationale: Sitting with crossed knees can compress veins, worsening venous stasis in clients with varicose veins.