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The healthcare provider is assessing a client who has just returned from hemodialysis. Which finding requires immediate intervention?
- A. Weight gain of 2 pounds.
- B. Dizziness.
- C. Blood pressure of 150/90 mm Hg.
- D. Heart rate of 88 beats per minute.
Correct Answer: B
Rationale: Dizziness after hemodialysis can indicate hypovolemia, hypotension, or other complications that require immediate intervention to prevent further deterioration or adverse events. Weight gain of 2 pounds may not be immediately concerning post-hemodialysis. A blood pressure of 150/90 mm Hg is slightly elevated but may not require immediate intervention unless accompanied by symptoms. A heart rate of 88 beats per minute falls within the normal range and may not be an immediate cause for concern after hemodialysis.
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The healthcare provider is inspecting the external eye structures of a client. Which finding is a normal racial variation?
- A. Blue sclerae.
- B. Brown macules on the sclerae.
- C. Slightly yellow sclerae in an African-American client.
- D. Conjunctival pallor.
Correct Answer: C
Rationale: The slightly yellow color of the sclera is a normal racial variation found in the African-American population. Blue sclerae (Choice A) are associated with osteogenesis imperfecta, not a normal racial variation. Brown macules on the sclerae (Choice B) may indicate issues like melanoma or melanosis but are not a normal racial variation. Conjunctival pallor (Choice D) suggests anemia or decreased blood flow but is not a normal racial variation.
The healthcare provider is developing a health education program for pregnant women on the importance of prenatal care. Which topic should be prioritized?
- A. the benefits of breastfeeding
- B. nutrition and weight gain during pregnancy
- C. the stages of fetal development
- D. signs and symptoms of preterm labor
Correct Answer: D
Rationale: Prioritizing the discussion on signs and symptoms of preterm labor is essential as it empowers pregnant women to recognize warning signs promptly and seek medical assistance to prevent potential complications. Understanding preterm labor signs, such as abdominal cramping, pelvic pressure, or vaginal bleeding, can lead to early intervention and improve maternal and fetal outcomes. While topics like breastfeeding benefits, nutrition during pregnancy, and fetal development stages are important, identifying signs of preterm labor takes precedence due to its immediate impact on maternal and fetal well-being.
A school nurse is developing a health risk screening protocol for use at an elementary school. What information is most important for the nurse to include in this protocol?
- A. annual flu vaccination status
- B. weight and height measurement
- C. total cholesterol level
- D. long bone deformity testing
Correct Answer: B
Rationale: Weight and height measurements are crucial components of health screenings in children as they help assess growth patterns and identify potential health concerns such as obesity or growth disorders. Monitoring weight and height regularly can aid in early intervention and prevention of health issues. Annual flu vaccination status, total cholesterol level, and long bone deformity testing are not typically primary components of routine health screenings in elementary school children and may not directly contribute to identifying common health risks in this population.
The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
- A. Ptosis on the left eyelid.
- B. Nystagmus.
- C. Astigmatism.
- D. Exophthalmos.
Correct Answer: A
Rationale: The correct answer is A: 'Ptosis on the left eyelid.' Ptosis is the term used to describe an eyelid droop that covers a large portion of the iris, which may be caused by issues with the oculomotor nerve or eyelid muscles. Choice B, 'Nystagmus,' refers to involuntary eye movements and is not related to eyelid drooping. Choice C, 'Astigmatism,' is a refractive error affecting vision due to an irregularly shaped cornea or lens, not an eyelid condition. Choice D, 'Exophthalmos,' is a protrusion of the eyeball associated with conditions like hyperthyroidism, not eyelid drooping.
The school nurse is coaching a group of high school students on ways to deal with the stress of final exams. Today the class is focusing on healthy food choices for lunch in the school cafeteria. Which option should the nurse recommend?
- A. cheeseburger on a whole wheat bun, French fries, and a large cola beverage
- B. tuna casserole with peas and corn, a fresh apple, crackers, and orange juice
- C. fruit salad with fresh berries and oranges, chicken vegetable soup, and tea
- D. chef salad with turkey, ham, and ranch dressing, apple juice, and milk
Correct Answer: C
Rationale: The recommended option for managing stress during final exams is a balanced and nutritious meal. Fruit salad with fresh berries and oranges, chicken vegetable soup, and tea offer a variety of nutrients and antioxidants that can help combat stress. Option A is not ideal as it includes high-fat and high-calorie foods. Option B is a good choice, but Option C provides a wider range of nutrients and hydration. Option D is a healthy choice with a variety of proteins and vitamins, but Option C offers lighter options that may be easier to digest during stressful times.