Nokea
The clinic nurse is seeing a client who suffers from caregiver strain due to caring for her elderly parents who have dementia and live with her. Which action by the nurse during the assessment is most important?
- A. ask the client about her support systems
- B. ask the client what she does for relaxation
- C. ask if her parents' insurance covers adult day care for them
- D. offer to give her a list of nursing homes to care for her parents
Correct Answer: A
Rationale: Assessing support systems identifies resources to alleviate caregiver strain, guiding interventions to reduce stress.
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A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:
- A. Pneumonia
- B. Reaction to antiviral medication
- C. Tuberculosis
- D. Superinfection due to low CD4 count
Correct Answer: C
Rationale: The symptoms of low-grade fever, blood-tinged hemoptysis, fatigue, and night sweats are classic for tuberculosis.
The nurse has just returned to the desk and has four phone messages to return. Which of the following messages should the nurse return FIRST?
- A. A woman in her first trimester of pregnancy complaining of heartburn.
- B. A man complaining of heartburn that radiates to his jaw.
- C. A woman complaining of hot flashes and difficulty sleeping.
- D. A boy complaining of knee pain after playing basketball.
Correct Answer: B
Rationale: indicates chest pain, needs to seek medical attention immediately
The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?
- A. Have you noticed a change in sleeping habits recently?
- B. Have you had a respiratory infection in the last 6 months?
- C. Have you lost weight recently?
- D. Have you noticed changes in your alertness?
Correct Answer: C
Rationale: Unexplained weight loss is a common symptom of leukemia due to increased metabolic demand and systemic effects of the disease.
Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
- A. A cephalhematoma
- B. Molding
- C. Subdural hematoma
- D. Caput succedaneum
Correct Answer: A
Rationale: A cephalhematoma is a subperiosteal hemorrhage that does not cross suture lines, commonly seen in newborns.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.